Lower GI problems
4.1 Diarrhea, Fecal Incontinence, and Constipation
a. Explain the common etiologies, collaborative care, and nursing management of diarrhea, fecal
incontinence, and constipation.
Factors affecting GI elimination:
-direct impact: intake/food, meds, pathogens/bacteria
-indirect impact: stress, avoid urge, depression
-normal bowel elimination: different for each person
*Normal bowel movement frequency varies from three bowel movements daily to one bowel movement
every 3 days.
Diarrhea:
-increased frequency
-passage of at least 3 loose liquid stools per day
-a “symptom” of something else
-causes = antibiotics, allergies, laxative abuse, bacteria
Etiology: Acute vs Chronic:
Acute:
-most commonly from infection (use contact precaution)
-ingestion of infectious organisms is the primary cause of acute diarrhea
-viruses (most common) = short lived
-bacteria = e coli
-parasites = g lamblia
-c. diff = gram positive, destroys cells in colon, causes inflammation, & can progress to
pseudomembranous colitis or perforation
-bile salts and undigested fats
-large amount of undigested carbohydrates produce osmotic diarrhea
-meds: some antibiotics kill off the normal flora
Chronic:
-longer than 4 weeks
-typically due to inflammatory bowel disorder
-genetic = an individual's susceptibility to pathogenic organisms is influenced by genetic susceptibility,
gastric acidity, intestinal microflora, and immunocompetence
-lactose intolerance
-laxatives = must ask patient about bowel movement before giving them
-celiac disease and short bowel syndrome = malabsorption in the small intestine
-crohn’s disease
-hyperbolic condition = exp. hyperthyroidism
Pathophysiology:
-some organisms destroy intestines directly, some organisms (c. diff) produce toxins that cause the
damage
-c. diff also causes inflammatory debris and dead cells that create a pseudomembranous barrier
Clinical Manifestations:
-systemic S&S = fatigue, malaise, dehydration, stomach cramps, nausea, dehydration, skin breakdown,
electrolyte disturbances (ex. hypokalemia), and acid-base imbalances (metabolic acidosis)
-c. difficile causes mild to severe diarrhea, abdominal cramping & fever (it can progress to fulminant
colitis and intestinal perforation)
-patients with c. difficile can also develop paralytic ileus or toxic mega-colon and require a colectomy
Diagnostic studies:
Lab Values:
-long standing diarrhea = decreased iron/folic acid can result in anemia
-fluid deficit = increased hemoglobin, hematocrit, blood urea nitrogen (BUN) & creatinine levels
-infectious diarrhea = elevated white blood cell (WBC) count
-c. diff = low albumin (it is determined by measurement of its toxins, toxins A and B)
-stools are examined for the presence of blood, mucus, WBCs & parasites (cultures are performed to
identify infectious organisms)
-chronic diarrhea = measurements of stool electrolytes, pH & osmolality help determine whether the
diarrhea is related to decreased fluid absorption or increased fluid secretion
-fat & protein malabsorption (pancreatic insufficiency) = measurement of stool fat & undigested muscle
fibers
-secretory diarrhea = elevated serum levels of GI hormones such as vasoactive intestinal polypeptide &
gastrin
Diagnostic Testing:
-stool culture = O&P, occult blood
-colonoscopy, capsule endoscopy
-double-balloon enteroscopy & colonoscopy may be used to examine the mucosa & obtain biopsies for
histologic examination
-capsule endoscopy is also used for visualization of the intestinal mucosa
Collaborative management:
assess put on contact precaution  stool sample (*lookup collection guidelines)
-contact precaution, eliminate causes, prevent dehydration, high fiber diet, avoid dairy, low fat diet
-depends on the cause (for acute diarrhea, replace lost F&E)
-strict infection control, wash hands before & after contact, flush vomit & stool in the toilet, wash
contaminated clothes immediately with soap & water, patient teaching
Pharmacology:
-antidiarrheal agents = only give for a short period of time
-coat and protect mucous membranes
-absorb irritating substances
-inhibit GI motility
-decrease intestinal secretions
-decrease central nervous system stimulation of the GI tract
Contraindications:
-infectious diarrhea – antidiarrheal agents potentially prolong exposure to the infectious organism
-used cautiously in inflammatory bowel disease - because of the danger of toxic mega-colon (colonic
dilation)
RN process: Assess & Intervene:
Subjective: history, physical examination: Ask the patient about recent travel to foreign countries,
medication use, diet, previous surgery, interpersonal contacts, and a family history of diarrhea.
Objective: vital signs & height/weight measurements. The patient's skin is inspected for signs of
dehydration (poor turgor, dryness, & areas of breakdown). The abdomen is inspected for distention,
auscultated for bowel sounds, & palpated for tenderness.
Constipation:
-common in elderly (over 65)
-it’s a decrease in frequency of bowel movements from what is “normal” for the individual
-also includes difficult-to-pass stool, a decrease in stool volume, and/or retention of feces in the rectum
-can be the primary problem or a symptom of something else
Etiology:
-insufficient dietary fiber, inadequate fluid intake
-decreased physical activity
-ignoring the defecation urge
-many medications, especially opioids, cause constipation
-chronic laxative use causes = cathartic colon syndrome, a condition in which the colon becomes dilated
and atonic (lacking muscle tone). Ultimately the person cannot defecate without the laxative
-diseases that slow GI transit and hamper neurologic function such as diabetes mellitus, Parkinson's
disease, and multiple sclerosis.
-emotions affect the GI tract, and both depression and stress can contribute to constipation
Clinical Manifestations:
-stools are absent or hard, dry, & difficult to pass
-abdominal distention, bloating, cramping, increased flatulence & increased rectal pressure
Complications:
-hemorrhoids are the most common complication of chronic constipation. They result from venous
engorgement caused by repeated Valsalva maneuvers (straining) & venous compression from hard
impacted stool
-in the presence of obstipation (severe constipation when no gas or stool is expelled) or fecal impaction
secondary to constipation, colonic perforation may occur. Perforation, which is life threatening, causes
abdominal pain, nausea, vomiting, fever, and an elevated WBC count
-rectal mucosal ulcers and fissures may also occur as a result of stool stasis or straining
-diverticulosis is another potential complication of chronic constipation
Diagnostic studies:
-abdominal x-rays, barium enema, colonoscopy, sigmoidoscopy, & anorectal manometry
-anorectal manometry, GI tract transit studies, & sigmoidoscopic rectal biopsies should be performed
before treatment
-in a patient with unrelenting constipation, a subtotal colectomy with ileorectal anastomosis is the
procedure of choice
RN process: Assess & Intervene:
Subjective:
-health history GI/neuro disease, cancer
-use of meds
-change in diet, weight, physical activity, stress
-describe stool, frequency
Objective:
-abdominal distention, hypoactive bowel sounds, fecal impaction
-diagnostics: xray to check for stool in the lower colon
-guaiac-positive stool
Intervention:
-prevention = increasing dietary fiber, fluid intake, and exercise
-laxatives & enemas may be used to treat acute constipation, but are used cautiously because overuse
leads to chronic constipation (the use of laxatives is discouraged)
-the recommended fluid intake may be contraindicated in the patient with cardiac disease or renal
insufficiency or failure
-teach pt to establish a regular time to defecate
-best position would be sitting with knees higher than the hips
-provide privacy
-exercise abdominal muscles
Pharmacology:
-daily bulk-forming preparations to prevent constipation
-stool softeners are also used to prevent constipation
-methylnaltrexone (Relistor) reduces constipation produced by opioid use
-enemas are fast acting and beneficial for immediate treatment of constipation
-contraindications: soapsuds enemas produce inflammation of colon mucosa, tap water enemas can
potentially lead to water intoxication & sodium phosphate enemas may cause electrolyte imbalances in
patients with cardiac and renal problems
Fecal impaction:
-prolonged retention of fecal matter becomes like a mass, prevents passage of more stool, sometimes a
small amount leaks around
-results from unrelieved constipation
-a collection of hardened feces
-an obvious sign of impaction is the inability to pass stool for several days, despite the repeated urge to
defecate
-intervention = Don’t give diuretics until you check if there is impaction. Unconscious patients are at risk,
do a digital exam. Orders: oil retention enema can be followed by soap suds, then digital removal. Can
cause bleeding and stimulation to vagus nerve.
Fecal incontinence:
Definition: involuntary passage of stool, loss of motor control of rectum
Risk factors: urinary stress incontinence, constipation & diarrhea
Etiology:
-occurs when the normal structures that maintain continence are disrupted
-damage to sphincters = anorectal surgery can damage the sphincter & radiation for prostate cancer
decreases rectal compliance
-weak pelvic muscles = constipated individuals tend to strain during defecation & straining contributes to
incontinence because it weakens the pelvic floor muscles; obstetric trauma (pregnancy); old age
-neurological issues = neurologic conditions (ex. stroke, spinal cord injury, m.s., parkinson's) & diabetic
neuropathy also interfere with defecation. The critically ill patient with decreased consciousness is unable
to perceive the defecation urge and delay defecation
-immobility = even people with normally functioning defecation experience incontinence if immobility
prevents timely access to a toilet
Clinical Manifestations:
-pain, leakage, urge to defecate
Subjective:
-assess the patient's overall condition and mental alertness
-ask about bowel patterns before the incontinence developed
-current bowel habits, stool consistency, frequency, symptoms, including pain during defecation and a
feeling of incomplete evacuation
-assess whether the patient has defecation urgency and is aware of leaking stool
-includes questions about daily activities (mealtimes and work), diet, family, social
-the Bristol Stool Scale is helpful for assessing stool consistency activities
Objective:
-physical exam: bowel assessment, assess stool
-check the perineal skin for irritation or breakdown
Diagnostics:
-rectal sphincter tone = a rectal examination can reveal the anal canal muscle tone & contraction strength
of the external sphincter, as well as detect internal prolapse, rectocele, hemorrhoids, fecal impaction, &
masses
-manometry = anorectal manometry, anorectal ultrasonography, anal manometry, & defecography
-sigmoidoscopy or colonoscopy = used to identify inflammation, tumors, fissures, polyps, hemorrhoids,
and other pathologies
-abdominal xray or CT scan = if the impaction is higher in the colon
Diagnosis:
-bowel incontinence, self-care deficit, risk for impaired skin integrity, social isolation
Goals:
-restore bowel pattern, maintain skin integrity, avoid self-esteem problems
Treatment: depends on the underlying cause
Medications:
-dietary fiber supplements or bulk-forming laxatives (Metamucil) can improve continence by increasing
stool bulk, firming consistency & promoting sensation of rectal filling
-an antidiarrheal agent (Imodium) is sometimes used to make stools firmer
Diet:
-high fiber, low residual, avoid fatty/spicy, increase fluids
-certain foods (coffee, dried fruit, onions, mushrooms, green vegetables, fruit with peels, spicy foods,
foods with monosodium glutamate) should be avoided because they tend to cause diarrhea & rectal
irritation
-follow the BRAT diet = bananas, rice, apples, toast
Exercise:
-kegel exercises are used to strengthen & coordinate the pelvic floor muscles in order to improve
continence
-biofeedback therapy is aimed at improving awareness of rectal sensation & coordination of the internal
& external anal sphincters & increasing the strength of external sphincter contraction
Surgery:
-sphincter repair procedures are considered only when conservative treatment fails, in cases of fullthickness prolapse & when the sphincter needs repair
-a colostomy is sometimes necessary
Teachings & Interventions:
-establish a regular time to defecate & teach to not suppress the urge to defecate
-the use of laxatives and enemas is discouraged
-the sitting position allows gravity to aid defecation & flexing the hips straightens the angle between the
anal canal and the rectum so that stool flows out more easily
-do not use diapers due to possible skin breakdown
-use chucks & keep area open to air, then change & turn patient q2h
-patients are encouraged to exercise abdominal muscles and to contract abdominal muscles several times
a day; sit-ups and straight-leg raises can also be used to improve abdominal muscle tone
4.2 Acute Abdominal Pain
a. Describe common causes of acute abdominal pain and nursing management of the patient
following an exploratory laparotomy.
Acute abdominal pain is a symptom associated with tissue injury. It can arise from damage to abdominal
or pelvic organs and blood vessels. Certain causes (ex. hemorrhage, obstruction, perforation, appendicitis,
& diverticulitis) can be life threatening because large fluid losses from the vascular space lead to shock
and abdominal compartment syndrome. Perforation of the GI tract also results in irritation of the
peritoneum (serous membrane that forms the lining of the abdominal cavity) and peritonitis.
Manifestations:
Pain is the most common symptom. The patient may also complain of nausea, vomiting, cramping,
diarrhea, constipation, flatulence, fatigue, fever & an increase in abdominal girth.
Assessment:
For the patient complaining of acute abdominal pain, take vital signs immediately. Increased pulse and
decreasing blood pressure (BP) are indicative of hypovolemia. An elevated temperature suggests an
inflammatory or infectious process. Intake and output measurement provides essential information about
the adequacy of vascular volume. Inspect the abdomen for distention, masses, abnormal pulsation,
symmetry, hernias, rashes, scars, and pigmentation changes. Auscultate bowel sounds. Bowel sounds that
are diminished or absent in a quadrant may indicate a complete bowel obstruction, acute peritonitis, or
paralytic ileus. Palpation should be gentle. Note any rebound tenderness.
-describe the pain (frequency, time, duration, location), PQRST
-accompanying symptoms
-PE: abdomen, rectum, pelvis
-CBC, urinalysis, xray, electrocardiogram, ultrasound, CT scan, pregnancy test (ectopic pregnancy)
-may use minimally invasive diagnostic laparoscopy as a last resort (ELap = exploratory laparoscopy)
-patient’s position:
a) fetal position means peritoneal irritation (appendicitis)
b) supine with outstretched legs means visceral pain
c) restlessness and seated means bowel obstruction or kidney stones or gallbladder stones
Implementation:
-management of fluid and electrolyte imbalances, pain, and anxiety
-assess the quality & intensity of pain at regular intervals & provide medication (Reglan which stimulates
peristalsis) & other comfort measures
-maintain a calm environment & provide information to help allay anxiety
-conduct ongoing assessments of vital signs, intake & output, & level of consciousness, which are key
indicators of hypovolemic shock
4.3 Appendicitis, Peritonitis, and Gastroenteritis
a. Describe the collaborative care and nursing management of acute appendicitis, peritonitis, and
gastroenteritis.
Appendicitis:
Definition:
-inflammation of the appendix, a narrow blind tube that extends from the inferior part of the cecum
Pathophysiology:
-paroximal lumen of the appendix narrows & becomes obstructed & inflamed
-the appendix then becomes extended which impairs oxygen/blood supply
-this causes edema/inflammation/purulent drainage, which turns into infection
-if left untreated for 1-3 days the tissue dies (necrosis)
-obstruction of the lumen can be caused by = accumulated feces, foreign bodies, tumor of the cecum or
appendix, or intramural thickening caused by excessive growth of lymphoid tissue, also viral or parasite
-obstruction results in distention, venous engorgement, & the accumulation of mucus & bacteria, which
can lead to gangrene (tissue death) & perforation
Complications:
-perforation from an abscess with fluid & bacteria that bursts
-peritonitis from the results of the perforation
-abscess causing sepsis
-if diagnosis & treatment are delayed, the appendix can rupture & the resulting peritonitis can be fatal
-if patient stops having symptoms suddenly, suspect ruptured appendix
Assessment:
Subjective data:
-generalized pain, nausea, pain increasing to the right lower quadrant, hurts when coughing/moving
-initial pain is peri-umbilical, followed by anorexia, nausea, & vomiting
-the pain is persistent & continuous, eventually shifting to the right lower quadrant (McBurney's point
which is located halfway between the umbilicus and the right iliac crest)
Objective data/Manifestations:
-palpation of the abdomen
-rigid, board-like abdomen
-rebound tenderness
-localized tenderness, rebound tenderness, and muscle guarding
-coughing, sneezing & deep inhalation magnify the pain
-patient usually prefers to lie still, often with the right leg flexed
-low-grade fever may or may not be present
-rovsings sign may be elicited by palpation of the LLQ, causing pain to be felt in the RLQ
-the older adult may report less severe pain, slight fever & discomfort in the right iliac fossa
Diagnostics:
-WBC count with differential (WBC’s will be elevated)
-Urinalysis (to rule out genitourinary conditions that mimic symptoms of UTI)
-Abdominal x-rays (to rule out ileus)
-Abdominal Ultrasound (most effective)
-Pelvic Examination
-CT scan (to check for abscess)
-IVP (to rule out UTI) = an intravenous pyelogram (IVP) is an x-ray examination of the kidneys, ureters
and urinary bladder that uses iodinated contrast material injected into veins
Treatment:
-immediate surgical removal (appendectomy) if the inflammation is localized
-if the appendix has ruptured & there is evidence of peritonitis or an abscess, conservative treatment
consisting of antibiotic therapy & parenteral fluids is given for 6-8 hours before the appendectomy to
prevent sepsis & dehydration
-surgery is generally performed laparoscopically (if not ruptured yet) & is performed as soon as the
diagnosis is made
-antibiotics and fluid resuscitation are administered before surgery
RN role:
Pre-op:
-seek medical treatment right away
-bed rest, IV fluids, frequent VS, pain meds, positioning
-no laxatives or enemas: increased peristalsis may cause perforation (rupture) of the appendix
-NPO in case they need surgery
-get consent for procedure
-ice may be applied to decrease inflammation, not heat (possible rupture)
-may use NG tube for decompression (to keep stomach empty)
Post-op:
-frequent vital signs, assess, pain control, assess skin & wounds, diet
-assess bandages (laparoscopic procedure), or gauze (open incision)
-teach patient about possible complications to look out for
-nursing management is similar to post-op care of the patient after laparotomy
-in addition, observe the patient for evidence of peritonitis
-ambulation begins the day of surgery or the first postoperative day
-diet is advanced as tolerated
-patient is usually discharged on the 1st or 2nd post-op day & normal activities are resumed 2-3 weeks later
Peritonitis: acute
Definition:
-results from a localized or generalized inflammatory process of the peritoneum
-inflammation of the lining of the abdomen (the lining that protects the organs)
-can be localized as an abscess (pocket of fluid, bacteria, etc.)
Pathophysiology:
-bacteria invades the peritoneum
-primary = blood born pathogen enters the peritoneal cavity (ex. cirrhosis provides liquid environment for
bacteria), adhesions(scar tissue) develop & necrose the tissue
-secondary = abdominal organs perforate or rupture & release their contents (bile, enzymes, bacteria) into
the peritoneal cavity (ruptured appendix, perforated gastric or duodenal ulcer, severely inflamed
gallbladder, obstruction, ulcerative colitis, trauma from gunshot or knife wounds)
Assessment:
Subjective data:
-abdominal pain (generalized, constant, intense)
Objective data:
-tenderness over the area, rebound tenderness, muscular rigidity/board-like, spasms
-tympany from gas/air upon percussion
-fever, fast/weak heart rate
Manifestations:
-distention, edema caused because of shift of fluid from vascular space into cells
-adhesions (scar tissue, fight infection)
-pain is generalized & constant, intense
-nausea/vomiting
-patients may lie very still & take only shallow respirations because movement causes pain
-abdominal distention or ascites, fever, tachycardia, tachypnea, nausea, vomiting & altered bowel habits
Diagnostics:
-CBC = elevation in WBC, fluid shifts
-peritoneal aspiration = fluid is analyzed for blood, bile, pus, bacteria, fungus, amylase content
-x-ray of abdomen = dilated loops of bowel consistent with paralytic ileus, free air if perforation has
occurred, or air and fluid levels if an obstruction is present
-ultrasound or CT scan = for presence of ascites and abscesses
-peritoneoscopy may be helpful in the patient without ascites (direct examination of the peritoneum can
be obtained along with biopsy specimens for diagnosis)
Complications:
-bleeding, peritonitis, infection, adhesions
-hypovolemic shock (from fluid shift), sepsis, intra-abdominal abscess formation, paralytic ileus, & acute
respiratory distress syndrome
-peritonitis can be fatal if treatment is delayed
Treatment:
-laparoscopic surgery = minimally invasive, small incisions (0.5-1.5 cm)
-laparotomy surgery = larger incisions
-if there is a rupture, must perform laparotomy
-bowel resection remove parts of the bowel (called colectomy)
-proctocolectomy removes the entire colon and rectum
-I&D = incision and drainage (to get abscess out)
-parasenthesis to aspirate fluid/air
Nursing care:
Pre op:
-monitor I&O, vital signs
-semi fowlers position
-NPO status
-IV fluid replacement, also for antibiotics
-may need NG tube to decrease distention and prevent further leakage
-analgesics (ex. morphine)
-oxygen PRN (low flow)
Post op:
-NPO status until bowel sounds return
-NG tube set to low-intermittent suction
-semi-fowler's position
-IV fluids with electrolyte replacement
-parenteral nutrition/blood transfusion PRN
-antibiotic therapy
-may have drains for pus or fluid
-sedatives and opioids
4.4 Chronic Abdominal Pain
a. Describe the collaborative care and nursing management of irritable bowel syndrome
Irritable Bowel Syndrome:
Definition:
-chronic diarrhea and/or constipation that alternates
-1-2 hours after eating, pain/bloating/gas starts, then stops when going to the bathroom
-a disorder, bowel irregularity
-affects twice as many women as men
-affects 10-15% of western populations
Causes:
-unknown, but altered bowel motility, heightened visceral sensitivity, inflammation & psychologic
distress are likely to be involved
-stress, also prior gastroenteritis, & specific food intolerances have been identified as major factors that
precipitate IBS symptoms
Manifestations (S&S):
-patient may also have abdominal distention, excessive flatulence, bloating, urgency, & sensation of
incomplete evacuation
-also non-GI symptoms, mainly fatigue and sleep disturbances
Assessment:
-history and physical
-emphasis should be on symptoms, past health history (including psychosocial factors such as physical or
sexual abuse), family history, and drug and diet history
-no specific findings
Diagnostic Testing:
-selectively used to rule out more serious disorders with symptoms similar to those of IBS, such as
colorectal cancer, inflammatory bowel disease, and malabsorption disorders (ex. celiac disease)
Treatment:
-directed at psychological and dietary factors, as well as medications to regulate stool output
Nursing Interventions:
-diet = eliminate gas producing foods, along with spicy & dairy
-psychological = stress & relaxation techniques (treat the symptoms, try & target the cause/stress)
-medications = loperamide (Imodium) & dicyclomine (bentyl) = anti-spasmatics
Gastroenteritis:
Definition:
-inflammation of the mucosa of the stomach and small intestine due to bacteria or virus
-there is no cure
-self-limiting
-causes an increase in GI motility
Manifestations:
-nausea, vomiting, diarrhea, abdominal cramping, and distention
-fever, increased WBC count, and blood or mucus in the stool may be present
Causes:
-often due to viral or bacterial infection
Diagnostic Testing:
-stool culture
Nursing Interventions:
-infection control, monitor I&O, control pain, rest, NPO until nausea stops, may give IV fluids & then
clear liquid diet, skin care, sitz bath, meds that slow motility (Reglan) and control spasms (Imodium)
b. Compare and contrast ulcerative colitis and Crohn's disease, including pathophysiology, clinical
manifestations, complications, collaborative care, and nursing management.
Inflammatory bowel disease:
-chronic, recurrent inflammation of the GI tract
-cause is unknown and there is no cure
-an autoimmune disease
-classified as either crohn's disease or ulcerative colitis based on clinical symptoms
-periods of remission and exacerbation
-treatment relies on meds to treat inflammation & maintain remission
-starts either in early adulthood or late in life
-risk factor: whites (mostly Jewish)
Ulcerative colitis:
Definition:
-usually starts in rectum & spreads in a continuous pattern up the colon
-inflammation & ulceration of the sigmoid colon & rectum
Pathophysiology:
-inflammation & abscesses will affect circulation & cause the lining to die & slough off
-then membranes break easily, causing bleeding/bloody stools
-lining will narrow & granulation will replace the muscular layer, making less folds
-loss of a lot of F&E because it cannot be absorbed through inflamed mucosa
-areas of inflamed mucosa form pseudopolyps, tongue-like projections into the bowel lumen
Manifestations:
-bloody diarrhea and abdominal pain
-fecal urgency, 10-20 loose stool per day
-tenesmus (spasmatic contraction of the anal sphincter)
-cramps, nausea, vomiting, dehydration, anemia, mucousy stool, bloating
-characterized by continuous colonic lesions
-complications include toxic mega-colon (dilation of colon - no peristalsis), risk for perforation, colorectal
cancer, rectal hemorrhaging
-severe cases can affect eyes
Crohn's Disease:
Definition:
-the inflammation involves all layers of the bowel wall
-can occur anywhere in the GI tract from the mouth to the anus, but occurs most commonly in the
terminal ileum and colon
-characterized by spontaneous remission
-skip lesions = segments of normal bowel can occur between diseased portions (ex. cobblestone look)
-strictures at the areas of inflammation may cause a bowel obstruction
-intestinal wall thickens (fibrosis) because of inflammation = narrowing of lumen with strictures
-inflammation spreads slowly & progressive
Manifestations:
-depends on location on GI tract
-acute: bloody diarrhea (less than ulcerative colitis), abdominal pain (relieved by defecation), constantly
tired, rectal bleeding, nausea, anemia, fissures (cut or tear in anus), semi-solid stool
Complications:
-since the inflammation goes through the entire wall, the microscopic leaks can allow bowel contents to
enter the peritoneal cavity and form abscesses or peritonitis
-fistulas can develop between the bowel and other organs
-malnutrition = anemia (from hemorrhaging) and fat malabsorption since terminal ileum is affected
-small intestine cancer
-bowel cancer
-obstruction
Crohns & UC:
-GI tract complications include hemorrhage, strictures, perforation (with possible peritonitis), fistulas, and
colonic dilation (toxic mega-colon)
-Risk for clots
-Kidney stones
-Systemic inflammation (artheritis)
-Subjective data = diarrhea, bloody stool, fatigue, abdominal pain, weight loss, fever
Diagnostics:
-CBC = check h&h for iron deficiency/anemia
-elevated WBC = toxic mega-colon or perforation
-low F&E, low albumin = malnutrition
-stool culture for infection, occult blood (anytime suspected bleed, do occult)
-sigmoidoscopy & colonoscopy = to determine area involved & to biopsy tissue (pre-op is enema or go
lightly drink)
-without biopsy = upper GI series (double-contrast barium enema), double-contrast study (in which air is
introduced into the bowel after the expulsion of barium) = to determine abnormalities
-capsule endoscopy (to diagnose Crohns mostly)
Goals:
(1) rest the bowel, (2) control the inflammation, (3) combat infection, (4) correct malnutrition, (5)
alleviate any stress, (6) provide symptomatic relief, and (7) improve quality of life.
Treatment:
-stop smoking
-medications = are chosen based on the location and severity of inflammation
-azulfidine (sulfas) = sensitive to light, reduces inflammation of colon (not tolerated by everyone)
-pentasa = decreases inflammation (newer, does not go through the whole colon)
-steroids = reduces inflammation, side effects mask the infection (never stop abruptly because it increases
blood sugar)
-immunosuppressive agents = if not responding to steroids (ex. methotrexate for crohn’s)
-antimicrobials = cipro & flagyl
-antiemetics = Zofran & fenergran
-lamodol (Imodium/anti diarrhetic) = not recommended because it can cause toxic mega-colon
-if anemic = vitamin b12 injections or folic acid or iron (cobalamin) via IM Z track
-nutrition= high-calorie, high-vitamin, high-protein, low-residue, lactose-free (if lactase deficiency) diet
-psychosocial = physical & emotional rest; referral for counseling and/or support group
Nursing Interventions:
-high fiber diet, or TPN
-monitor I&O, monitor bowels, monitor dehydration
-assess labs, stool
-meds (witch hazel) & sitz baths
-rest & don’t use diapers
Surgery:
-reserved for emergency situations (excessive bleeding, obstruction, peritonitis) or when medical
treatment has failed
-not 100% curative
Crohn’s:
-bowel resection = to remove diseased part of the bowel and anastomose the ends together (strictoplasty)
or to repair parts
-this can cause malabsorption or short bowel syndrome
Ulcerative Colitis:
-total colectomy (removal of colon)
-ileostomy, Kock's ileostomy, ileoanal reservoir
-an ostomy in the ileum is called an ileostomy
-an ostomy in the colon is called a colostomy
-ileostomy = created by bringing a portion of the ileum (small intestine) through an opening in the
abdomen. discharge is fairly constant & watery & contains large amounts of salts and digestive enzymes
-characteristics of stool = the more distal, stool will be more formed
-Kock's ileostomy/pouch (continent) =
acts as a reservoir, insert a catheter through which content goes out, very rare, advantage is no external
pouch needed & can control elimination
-Total colectomy with ileoanal reservoir (continent) =
create j pouch, ostomy is temporary, most common, 2 stages, colectomy 1st, ileostomy redirected 2nd
-surgical procedures used to treat chronic ulcerative colitis include (1) total colectomy with rectal mucosal
stripping and ileoanal reservoir, (2) total proctocolectomy with permanent ileostomy, and (3) total
proctocolectomy with continent ileostomy (Kock pouch). Not recommended.
-ostomy = surgical opening
-stoma = opening with collection bag
-ostomy care = chew food, avoid gassy foods, increase fluid intake
4.5 Intestinal Obstruction
a. Differentiate among mechanical, neurogenic, and vascular bowel obstructions, including causes,
collaborative care, and nursing management.
-intestinal content cannot pass through the GI tract, a blockage
-mechanical = detectable occlusion of the intestinal lumen (from surgical adhesions, hernias, tumors,
carcinoma, volvulus, diverticular disease); SBO is common
-causes of mechanical obstruction = adhesions, strangulated inguinal hernia, ileocecal intussusceptions,
intussusception from polyps, mesenteric occlusion, neoplasm, volvulus of the sigmoid colon (bowel
twisting itself)
-non mechanical (functional) = neuromuscular or vascular disorder (rare, clot or atherosclerosis)
-at risk for paralytic ileus (no peristalsis) & pseudo-obstruction
-a characteristic sign of mechanical obstruction is pain that comes and goes in waves
-in the small intestine = vomiting right away
-in the large intestine = severe continuous pain with nausea, but may not vomit at first
Manifestations:
-distention, nausea, vomiting
-vomit can smell like feces or be coffee ground emesis
-pain
-at risk for hypo-volemia & shock & strangulated bowel
-bowel sounds = high pitched above area of obstruction, bowel sounds can be absent but may be also
hyperactive
Diagnostic Testing:
-with contrast = need consent & must ask about allergies (to dye) & assess renal function (for dye)
-abdominal x-rays & CT scans = most useful, show presence of gas (perforation) or fluid
-WBC = an elevated count may indicate strangulation or perforation
-electrolytes = likely to have an imbalance
-barium enema = for large bowel obstruction
-colonoscopy & sigmoidoscopy = show direct visualization of the obstruction
Treatment:
-the goals of surgery are to relieve the obstruction & pressure
-occasionally obstructions can be removed non-surgically
-a colonoscopy can be used to remove polyps, dilate strictures, & remove & destroy tumors with a laser
-NG tube (know different tubes) = salem sump is used for decompression of air/fluid
Complications:
-hypovolemia, hypokalemia, septic shock, tissue may become necrotic
4.6 Colorectal Cancer/Polyps of the Large Intestine
a. Describe the clinical manifestations and collaborative management of polyps of the large
intestine, and colorectal cancer.
Background:
-2nd leading cause of death from cancer
-high in African Americans
-affects more men than women
-with early diagnosis, high 5 year survival rate
Risk Factors:
-family history, increasing age, lifestyle and diet, inflammatory bowel disease, polyps
-adenomatous polyps are linked to CRC
Pathophysiology:
-polyps grow and penetrate mucosa, access lymph nodes, spread to liver and other organs
Complications:
-obstruction, bleeding, peritonitis, perforation, fistula formation
Manifestations:
-do not manifest until advanced stage (maybe some bleeding)
-right colon = asymptomatic
-left side = change in elimination
Diagnostics:
-colonoscopy = check for polyps (gold standard). every 10 years starting at age 50. (african americans go
at age 45)
-testing the stool for fecal blood & DNA (occult blood) = must be done frequently
-once CRC is diagnosed = check CBC to check for anemia, coagulation studies & liver function tests
-CT scan or MRI of the abdomen may be helpful in detecting liver metastasis, retroperitoneal & pelvic
disease, and depth of penetration of tumor into the bowel wall
-however, liver function tests may be normal even when metastasis has occurred
-CEA lab work?
Treatment:
-focus is on early detection & intervention
-surgical resection of tumor
-colostomy = temporary to promote healing of bowel & permanent if cannot repair rectum
-double bowel colostomy = double barreled stoma: proximal for bowel, distal for mucus to go out
-transverse loop colostomy = emergency, suspends loop of bowel over a bridge & brings it through the
skin; temporary to allow bowels to heal for 2-3 months
-end stoma = permanent colostomy (unless it’s reversed)
-hartman’s procedure = in distal portion of colon; during this procedure, the lesion is removed, the distal
bowel is sewn up & closed intra-peritoneally & the proximal bowel is diverted with a stoma; possible to
reverse procedure after bowel has rested temporarily (gunshot wound, trauma, etc.)
-chemotherapy = used pre-operatively
-radiation therapy = used post-operatively
4.7 Ostomy Surgery
a. Explain the anatomic and physiologic changes and nursing management of the patient with an
ileostomy and colostomy.
Total Proctocolectomy With End Ileostomy
This procedure involves the complete removal of the large bowel, including the rectum and the anal
sphincter. This results in the creation of a permanent stoma.
Kocks pouch/rarely used
This is the complete removal of the large bowel, including the rectum and the anal sphincter. An internal
reservoir is created which must be drained by inserting a catheter through an abdominal stoma on a
regular routine, several times a day.
Total Colectomy With Ileoanal Reservoir
Removal of the entire large bowel and inner lining of the rectum, leaving a rectal cuff. Preserves the
nerves and muscles necessary for continence. The last portion of the small bowel is used to construct an
internal pouch. This pouch has a short spout which is brought down through the rectal cuff and joined to
the anus. This pouch may be constructed in several different ways most commonly a “J” pouch.
Ostomy:
-should be beet/brick red (viable stoma mucosa)
-dark red/purple/blue indicates inadequate blood supply
-assess size and color, location, check if it’s working
-flatus is expelled from the bag through a charcoal filter that helps control odor
-ileostomy (within 24 hours green stool) after colostomy (may take a few days)
-colostomy irrigation is used to stimulate emptying of the bowel
-stoma irrigation?
-if cramping occurs?
4.8 Diverticulosis and Diverticulitis
a. Differentiate between diverticulosis and diverticulitis, including clinical manifestations,
collaborative care, and nursing management.
Diverticula:
-saccular dilations or out-pouchings/herniations of the mucosa that develop in the colon
-diverticula may occur at any point within the GI tract but are most commonly found in the sigmoid colon
-cause is unknown, may be from diet low in fiber
Diverticulosis:
Multiple non-inflamed diverticula are present in diverticulosis. No symptoms, may progress to
diverticulitis.
Diverticulitis:
Inflammation of the diverticula, resulting in perforation into the peritoneum. Complications such as
perforation, abscess, fistula, and bleeding may occur.
S&S:
-abdominal pain is localized over the involved area of the colon
-the most common symptoms of diverticulitis in the sigmoid colon include left lower quadrant abdominal
pain and sometimes fever & nausea
Treatment:
-In acute diverticulitis, the goal of treatment is to let the colon rest and the inflammation subside
-Some patients can be managed at home with oral antibiotics and a clear liquid diet
-If hospitalized, the patient is kept on NPO status and bed rest, and fluids and IV antibiotics are given
-Observe for signs of abscess, bleeding, and peritonitis, and monitor the WBC count
-When the acute attack subsides, give oral fluids first and then progress the diet to semisolids
-Ambulation is allowed
4.9 Hernias
a. Compare and contrast the types of hernias, including etiology and surgical and nursing
management
Definition:
-a protrusion of a viscus through an abnormal opening or a weakened area in the wall of the cavity in
which it is normally contained
-usually occurs in the abdomen
-hernias that easily return to the abdominal cavity are called reducible
-the hernia can be reduced manually or may reduce spontaneously when the person lies down
-if the hernia cannot be placed back into the abdominal cavity, it is known as irreducible or incarcerated
-in this situation the intestinal flow may be obstructed/the hernia is strangulated & the result is an acute
intestinal obstruction
Treatment:
-laparoscopic surgery
-the surgical repair of a hernia is known as a herniorrhaphy, & is usually an outpatient procedure
-some patients with hernias wear a truss, a pad placed over the hernia & held in place with a belt (the truss
is worn to keep the hernia from protruding)
-after a hernia repair, the patient may have difficulty voiding (observe for a distended bladder)
-an accurate intake and output record is important
-scrotal edema is a painful complication after an inguinal hernia repair
-a scrotal support with application of an ice bag may help relieve pain and edema
-coughing is not encouraged, but deep breathing and turning should be done
-if the patient needs to cough or sneeze, the incision should be splinted during coughing & sneezing
should be done with the mouth open
-after discharge the patient may be restricted from heavy lifting for 6 to 8 weeks
4.10 Malabsorption Syndrome
a. Describe the types of malabsorption syndrome and collaborative care of sprue syndrome, lactase
deficiency, and short bowel syndrome.
-malabsorption results from impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins
-the most common signs of malabsorption are weight loss, diarrhea, and steatorrhea (bulky, foulsmelling, yellow-gray, greasy stools with putty-like consistency)
-steatorrhea does not occur with lactose intolerance
-celiac disease is an autoimmune disease characterized by damage to the small intestinal mucosa from the
ingestion of wheat, barley, and rye in genetically susceptible individuals
-lactase deficiency is a condition in which the lactase enzyme is deficient or absent
-short bowel syndrome (SBS) results from surgical resection, congenital defect, or disease-related loss
of absorption. It is characterized by failure to maintain protein-energy, fluid, electrolyte, and
micronutrient balances on a standard diet
-resection of the small intestine may be necessary for bowel infarction because of vascular thrombosis or
insufficiency, abdominal trauma, cancer, radiation enteritis, or Crohn's disease.
-interventions include: diets high in carbs & low in fat, 6 meals a day, & opioid anti-diarrheal meds
4.11 Hemorrhoids
a. Describe the types, clinical manifestations, collaborative care, and nursing management of
anorectal conditions
-dilated hemorrhoidal veins
-may be internal (occurring above the internal sphincter) or external (occurring outside the external
sphincter)
-symptoms include rectal bleeding, pruritus, prolapse, and pain
-in affected persons, hemorrhoids appear periodically, depending on the amount of anorectal pressure
-they are thought to develop as a result of increased anal pressure and weakened connective tissue that
normally supports the hemorrhoidal veins
-the most common reason for bleeding with defecation
-the amount of blood lost at one time may be small but over time may lead to iron-deficiency anemia
-hemorrhoids may be precipitated by many factors, including pregnancy, prolonged constipation,
straining in an effort to defecate, heavy lifting, prolonged standing and sitting, and portal hypertension (as
found in cirrhosis)