Lower GI Disorders
Factors Affecting GI Elimination
 Direct Impact
 Food you take in
 Normal Flora
 Intake of bacteria
 Indirect Impact
 Stress (bad news, exams)
 Voluntary postponement (holding it in)
 Normal Bowel Elimination
 Varies person to person
1
Lower GI Disorders
PROBLEM
Diarrhea
DEFINITION:
PATHOPHYSIOLOGY/ ETIOLOGY / RISK FACTORS
CLINICAL MANIFESTATIONS
Passage of at least
three loose or
liquid stools per
day.
PATHOPHYSIOLOGY
 Infectious organisms attack the intestines in
various ways
 Bacteria that attack the cells of the colon
cause inflammation and systemic symptoms
ACUTE DIARRHEA
 Inflammation and systemic
symptoms
o fever, headache, malaise
 Nausea, vomiting
 Abdominal cramping and liquid
stool.
 Perianal skin irritation. r/t loose
stool
 Leukocytes, blood, and mucus may
be in the stool
 Self-limiting in the adult.
 Contagious for 2 weeks or more
even after recovering from a viral
infection.
ACUTE OR
CHRONIC
Acute:
 Less than 4
weeks
Chronic
 Greater than 4
weeks
ACUTE DIARRHEA R/T:
 Ingestion of infectious organisms is the
primary cause of acute diarrhea
o Clostridium difficile, Escherichia coli,
Salmonella
 Antibiotics
o C. difficile is the most serious
antibiotic-associated diarrhea
 Viruses
o Most infectious diarrhea in the
United States is caused by viruses
o Short lived (48 hours)
 Susceptibility to pathogenic organisms is
influenced by genetic susceptibility, gastric
acidity, intestinal microflora, and
immunocompetence.
CHRONIC DIARRHEA R/T
 Lactose intolerance
 laxatives (e.g., lactulose)
 osmotic diarrhea (Large amounts of
undigested carbohydrate in the bowel)
 celiac disease
 Short bowel syndrome results from
malabsorption in the small intestine
 Crohn’s disease
SEVERE DIARRHEA produces lifethreatening
 Dehydration, electrolyte
disturbances (e.g., hypokalemia),
and acid-base imbalances
(metabolic acidosis)
 C. Difficile
o Develop paralytic ileus
o toxic megacolon and require
a colectomy
 Elderly are particularly vulnerable to
severe diarrhea
CHRONIC DIARRHEA
 malabsorption and ultimately
malnutrition
2
COLLABORATIVE CARE / DIAGNOSTIC
STUDIES:
DIAGNOSTIC STUDIES
 Culture Stool
o Bacteria, parasites +
 CBC
o WBC ↑
 Occult Blood +
 Colonoscopy +
 Capsule endoscopy
COLLABORATIVE CARE
 Treatment depends on the cause
 Foods and medications that cause
diarrhea should be avoided.
 Preventing transmission
 Fluid and electrolyte replacement,
and resolution of the diarrhea.
 Oral Liquids w/ glucose and
electrolytes (e.g., Gatorade,
Pedialyte) to replace losses from
mild diarrhea
 IV administration of fluids,
electrolytes, vitamins, and nutrition
if losses are severe
 Antidiarrheal agents
o DO NOT GIVE UNLESS
CAUSE IS KNOWN; or
INFECTION
o Only for a short time
 Antibiotics (bacteria)
Lower GI Disorders
NURSING MANAGEMENT
Diarrhea
ASSESSMENT:
HISTORY – SUBJECTIVE
 Stool pattern and associated symptoms
o Duration, frequency, character, and
consistency
o Pain
 Medication history antibiotics, laxatives,
and other drugs known to cause diarrhea.
 Recent travel, stress, and health and
family illnesses
 Surgery or other treatments: Stomach or
bowel surgery, radiation
 Eating habits, greasy and spicy foods,
food intolerances; anorexia, nausea,
vomiting; weight loss; thirst milk and
dairy products, and food prep practices.
DIAGNOSIS

Diarrhea related to
acute infectious process

Deficient fluid volume
r/t excessive fluid loss
and decreased fluid
intake secondary to
diarrhea as evidenced by
dry skin and mucous
membranes, poor skin
turgor, orthostatic
hypotension,
tachycardia, decreased
urine output, electrolyte
imbalance
PLANNING - GOAL
Patient will:
 No transmission of the
microorganism causing the
infectious diarrhea

Cessation of diarrhea and
resumption of normal
bowel patterns
INTERVENTIONS
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Normal fluid and electrolyte
and acid-base balance
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Normal nutritional status
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No perianal skin
breakdown.
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PHYSICAL EXAMINATION - OBJECTIVE
 Vital signs and height and weight.
 Skin inspected for signs of dehydration
(poor turgor, dryness, pallor and perianal
irritation).
 Lethargy, sunken eyeballs, fever,
malnutrition
 Abdomen is inspected for distention,
auscultated for bowel sounds (↑
hyperactive bowel), and palpated for
tenderness.
 Decreased urine output, concentrated
urine
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Possible Diagnostic Findings
 Abnormal serum electrolyte levels;
anemia; leukocytosis; hypoalbuminemia; +
stool cultures; presence of ova, parasites,
leukocytes, blood, or fat in stool;
abnormal sigmoidoscopy or colonoscopy
findings; abnormal lower GI series
Strict infection control
precautions Wash your hands
before and after contact
Flush stool in the toilet
C. Diff use soap & water; placed
on contact precaution (gloves &
gowns)
Encourage oral fluids
Maintain a steady IV infusion
Monitor I&O
Monitor vital signs to detect
hypovolemia
Administer prescribed
electrolytes
Monitor lab (hematocrit, BUN,
albumin, total protein, serum
osmolality, and urine specific
gravity levels)
Administer prescribed
medications
o C. Diff – Flagyl or
Vancomycin,
metronidazole (for mild
cases)
Keep area dry, clean, use
protective barrier, sitz bath
Perform actions to rest bowel
(e.g., NPO, liquid diet).
↑ Fiber (Bulk-Forming)
TEACH :
 Principles of hygiene, infection
control precautions, and the
potential dangers of an illness
that is infectious to themselves
and others.
 Discuss proper food handling,
cooking, and storage
3
EVALUATION
Lower GI Disorders
PROBLEM
Fecal Incontinence
DEFINITION:
Involuntary passage of stool,
occurs when the normal
structures that maintain
continence are disrupted
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
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CLINICAL MANIFESTATIONS
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES
 Rectal examination can reveal the
anal canal muscle tone and
contraction strength of the external
sphincter, as well as detect internal
prolapse, rectocele, hemorrhoids,
fecal impaction, and masses
 Abdominal x-ray or a computed
tomography (CT)
 Sigmoidoscopy or colonoscopy is
used to identify inflammation,
tumors, fissures, and other
pathology.
 Lab work
Problems with motor function (contraction
of sphincters and rectal floor muscles)
and/or sensory function (ability to perceive
the presence of stool or to experience the
urge to defecate)
Weakness or disruption of the internal or
external anal sphincter
Women: Childbirth, aging, and menopause
Urinary stress incontinence
Constipation, and diarrhea
Fecal impaction - liquid stool seeps around
the mass of hardened feces
Anorectal surgery for hemorrhoids, fistula,
and fissures (nerve damage)
Neurologic conditions (e.g., stroke, spinal
cord injury, multiple sclerosis, Brain tumor
Parkinson's disease) and diabetic
neuropathy
Infection
Decreased consciousness
Constipation straining contributes to
incontinence because it weakens the pelvic
floor muscles
COLLABORATIVE CARE
 Dietary fiber supplements or bulkforming laxatives (e.g., psyllium in
Metamucil) by increasing stool bulk
 NPO=Rest bowel
 BRAT Diet →Avoid (e.g., coffee,
dried fruit, onions, mushrooms,
green vegetables, fruit with peels,
spicy foods, foods with
monosodium glutamate)
 Antidiarrheal agent [Imodium]
 Increase fluid
 Kegel Exercise
 Bowel Training
 Surgery (e.g., sphincter repair
procedures)
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Lower GI Disorders
NURSING MANAGEMENT
Fecal Incontinence
ASSESSMENT:
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Be sensitive to the patient's
feelings when discussing
incontinence because
embarrassment and shame may
hamper willingness to discuss it
When the underlying cause cannot
be corrected, you can help the
patient reestablish a predictable
pattern of defecation.
assess the patient's overall
condition and mental alertness.
Ask about bowel patterns before
the incontinence developed,
current bowel habits, stool
consistency, stooling frequency,
and symptoms, including pain
during defecation and a feeling of
incomplete evacuation.
Assess whether the patient has
defecation urgency and is aware of
leaking stool.
Check the perineal skin for
irritation or breakdown.
Questions about daily activities
(e.g., mealtimes and work), diet,
and family and social activities.
DIAGNOSIS
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Bowel incontinence related to
inability to control bowel function
Self-care deficit (toileting) related
to inability to manage bowel
evacuation voluntarily
Risk for situational low selfesteem related to inability to
control bowel movements
Risk for impaired skin integrity
related to incontinence of stool
Social isolation related to inability
to control bowel functions
PLANNING - GOAL
Patient will:
 Have predictable bowel
elimination,
 Maintain perianal skin
integrity
 Participate in work and
social activities
 Avoid self-esteem
problems related to
problems with bowel
control.
INTERVENTIONS
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Establish Bowel Routine
Placement on a bedpan, assistance
to a bedside commode, or walking
to the bathroom at a regular
Gastrocolic reflex is strongest in
most people right after breakfast.
Good time to schedule elimination
is within 30 minutes after
breakfast.
Reestablishing bowel regularity, a
bisacodyl (Dulcolax) glycerin
suppository or a small phosphate
enema may be administered 15 to
30 minutes before the usual
evacuation time.
Irrigation of the rectum and colon
(usually with tap water) at regular
intervals is another method to
achieve continence
Maintain skin integrity
Meticulous cleaning after each
stool is essential for skin integrity.
The skin is cleaned with a mild
soap and rinsed to remove feces,
the area is dried, and a protective
skin barrier cream is applied
TEACH:
 Avoid foods such as caffeine that
worsen symptoms. In addition,
exercising after meals can
aggravate symptoms of
incontinence
5
EVALUATION
Lower GI Disorders
PROBLEM
Constipation
DEFINITION:
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
A decrease in frequency of
bowel movements from what is
“normal” for the individual.
Constipation also includes
difficult-to-pass stools, a
decrease in stool volume,
and/or retention of feces in the
rectum.
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Normal bowel movement
frequency varies from three
bowel movements daily to one
bowel movement every 3 days.
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Insufficient fiber, inadequate fluid intake,
decreased physical activity, and ignoring the
defecation urge
Post-op
Medications, especially opioids
diseases that slow GI transit and hamper
neurologic function such as diabetes
mellitus, Parkinson's disease, and multiple
sclerosis
depression and stress
Chronic: Scar tissue / Adhesions
Over use of laxatives
Ignoring the urge to defecate
o prolonged retention of feces results
in drying of stool due to water
absorption
CLINICAL MANIFESTATIONS
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6
Stools are absent or hard, dry, and
difficult to pass.
Abdominal distention, bloating,
increased flatulence
Increased rectal pressure may also be
present.
Hemorrhoids are the most common
complication of chronic constipation
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
Diverticulosis (common in older
patients
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES:
 Abdominal x-rays, barium enema,
colonoscopy, sigmoidoscopy, and
anorectal manometry
COLLABORATIVE CARE
 Prevented by increasing dietary
fiber, fluid intake, and exercise.
 Laxatives and enemas may be used
to treat acute constipation, but are
used cautiously because overuse
leads to chronic constipation.
Lower GI Disorders
NURSING MANAGEMENT
Constipation
ASSESSMENT:
Subjective Data Past health history:
Colorectal disease, neurologic dysfunction,
bowel obstruction, IBS
Medications: Use of aluminum and calcium
antacids, anticholinergics, antidepressants,
antihistamines, opioids, iron, laxatives,
enemas
Health perception–health management:
Chronic laxative or enema abuse; rigid
beliefs regarding bowel function; malaise
Nutritional-metabolic: Changes in diet or
mealtime; inadequate fiber and fluid
intake; anorexia, nausea
Elimination: Change in usual elimination
patterns; hard, difficult-to-pass stool,
decrease in frequency and amount of stools
Activity-exercise: immobility; sedentary
lifestyle
Cognitive-perceptual: Dizziness, headache,
anorectal pain; abdominal pain on
defecation
Coping–stress tolerance: Acute or chronic
stress
Objective Data
General
Lethargy
Integumentary
Anorectal fissures, hemorrhoids, abscesses
Gastrointestinal
Abdominal distention; hypoactive or absent
bowel sounds; palpable abdominal mass;
fecal impaction; small, hard, dry stool; stool
with blood
Possible Diagnostic Findings
Guaiac-positive stools; abdominal x-ray
demonstrating stool in lower colon
DIAGNOSIS
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Constipation related to
inadequate intake of
dietary fiber and fluid
and decreased physical
activity
PLANNING - GOAL
Patient Will:
 Increase dietary intake of fiber
and fluids
 Increase physical activity
 Pass soft, formed stools; and
 Not have any complications,
such as bleeding hemorrhoids.
INTERVENTIONS
TEACH
 Eat Dietary Fiber
 Drink Fluids
 Exercise Regularly
 Establish a Regular Time to
Defecate
o Best time AM, muscles
are relaxed
 Do Not Delay Defecation
 Record Your Bowel Elimination
Pattern
 Avoid Laxatives and Enemas
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Bed rest give bed pan- fowlers
position
If allowed OOB
Get patient walking
EVALUATION
Lower GI Disorders
PROBLEM
ACUTE PAIN
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
DEFINITION:
Symptom associated with tissue
injury.
It can arise from damage to
abdominal or pelvic organs and
blood vessels.
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Abdominal compartment syndrome
Acute pancreatitis
Appendicitis
Bowel obstruction
Cholecystitis
Diverticulitis
Gastroenteritis
Pelvic inflammatory disease
Perforated gastric or duodenal ulcer
Peritonitis
Ruptured abdominal aneurysm
Ruptured ectopic pregnancy
CLINICAL MANIFESTATIONS
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Pain is the most common
Nausea, vomiting, diarrhea,
constipation, flatulence, fatigue,
fever, and an increase in abdominal
girth.
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES
 Complete blood count (CBC),
urinalysis, abdominal x-ray, and
electrocardiogram are done
initially, along with an ultrasound or
CT scan.
 A pregnancy test is performed in
women of childbearing age with
acute abdominal pain to rule out
ectopic pregnancy
COLLABORATIVE CARE
 Note the patient's position.
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fetal posture is common with
peritoneal irritation (e.g.,
appendicitis)
 Supine posture with outstretched
legs is seen with visceral pain, and
restlessness and a seated posture
commonly occur with bowel
obstructions and obstructions from
kidney stones and gallstones
 Careful use of pain medications
(e.g., morphine) provides pain relief
without interfering with diagnostic
accuracy
 Laparoscopy to inspect obtain
biopsy specimens, perform
laparoscopic ultrasounds & provide
treatment
8
Lower GI Disorders
NURSING MANAGEMENT
Acute Pain
ASSESSMENT:
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Make a thorough assessment
of the patient's symptoms to
determine the onset,
location, intensity, duration,
frequency, and character of
pain. PQRST
Note whether the pain has
spread or moved to new
locations (quadrants), as well
as what makes the pain
worse or better.
Is the pain associated with
other symptoms, such as
nausea, vomiting, changes in
bowel and bladder habits, or
vaginal discharge in women?
Assessment of vomiting
includes the amount, color,
consistency, and odor of the
emesis.
Also assess bowel patterns
and habits.
DIAGNOSIS
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Acute pain related to
inflammation of the peritoneum
and abdominal distention
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Risk for deficient fluid volume
related to collection of fluid in
peritoneal cavity secondary to
inflammation or infection
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PLANNING - GOAL
Patient will:
 Resolution of inflammation
 Relief of abdominal pain
 Freedom from complications
(especially hypovolemic
shock)
 Normal nutritional status.
Imbalanced nutrition: less than
body requirements related to
anorexia, nausea, and vomiting
INTERVENTIONS
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General care for the patient involves
management of fluid and electrolyte
imbalances, pain, and anxiety
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Assess the quality and intensity of
pain at regular intervals, and provide
medication and other comfort
measurements. Maintain a calm
environment and provide information
to help allay anxiety.
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Anxiety related to pain and
uncertainty of cause or outcome
of condition
Conduct ongoing assessments of vital
signs, intake and output, and level of
consciousness, which are key
indicators of hypovolemic shock.
POST-OP CARE
 Nasogastric (NG) tube with low
suction decompress & empty
 Drainage from the NG tube may be
dark brown to dark red for the first 12
hours. Later it should be light
yellowish brown
 Bright red blood = Call Dr.= Possible
Hemorrhage
 Coffee-ground= modified by acidic
gastric secretions.
 Green=Bile
 NPO
 Give Anti-emetics
 Early ambulation helps restore
peristalsis and eliminate flatus and
gas pain
9
EVALUATION
•Resolution of
the cause of
the acute
abdominal
pain
•Relief of
abdominal
pain and
discomfort
•Freedom
from
complications
(especially
hypovolemic
shock and
septicemia)
•Normal fluid,
electrolyte,
and nutritional
status
Lower GI Disorders
PROBLEM
CHRONIC ABDOMINAL PAIN
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
DEFINITION:
May originate from
abdominal structures or may
be referred from a site with
the same or a similar nerve
supply.
Common causes include:
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irritable bowel syndrome (IBS),
diverticulitis,
peptic ulcer disease,
chronic pancreatitis,
hepatitis,
cholecystitis,
pelvic inflammatory disease,
vascular insufficiency.
CLINICAL MANIFESTATIONS
Chronic abdominal pain is often
described as dull, aching, or diffuse.
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES
 Endoscopy, CT scan, magnetic
resonance imaging (MRI),
 Laparoscopy, and barium
studies may be used in the
patient evaluation.
COLLABORATIVE CARE
 Thorough history and
description of specific pain
characteristics.
 Character and severity of pain,
location, duration, and onset
should be determined.
 Assessment also includes the
relationship of pain to meals,
defecation, and activity
 Factors that increase or
decrease the pain.
 Treatment for chronic
abdominal pain is
comprehensive and directed
toward palliation of symptoms
 Nonopioid analgesics and
antiemetics
 Psychologic or behavioral
therapies (e.g., relaxation
therapies).
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Lower GI Disorders
PROBLEM
DEFINITION:
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Chronic functional disorder
characterized by
intermittent and recurrent
abdominal pain and stool
pattern irregularities
(diarrhea, constipation, or
both).
IBS affects approximately
10% to 15% of Western
populations
Affects twice as many
women as men
Irritable Bowel Syndrome
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
Cause of IBS is unknown:
IBS is a multicomponent disorder, which can
make it challenging for both the patient and care
provider.
CAN BE R/T
 Altered bowel motility, heightened visceral
sensitivity, inflammation, and
 Psychological distress
o depression, anxiety, and
posttraumatic stress
 Prior gastroenteritis
 Impaired GI motility
 Specific food intolerances
CLINICAL MANIFESTATIONS
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Alternating diarrhea/constipation
o Stool pattern irregular
Abdominal distention
Excessive flatulence
Bloating
Urgency
Sensation of incomplete evacuation
After BM has relief
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES
 Tests are 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 (e.g., celiac
disease).
 Rome III criteria include the
following: abdominal discomfort or
pain for at least 3 months, with
onset at least 6 months before that
has at least two of the following
characteristics: (1) relieved with
defecation; (2) onset associated
with a change in stool frequency; (3)
onset associated with a change in
stool appearance.
COLLABORATIVE CARE
Based on: Dominant symptoms and on
psychosocial factors
DIET:
 Eliminate gas producing foods
 Keep Food Diary, symptoms, diet,
and episodes of stress
 ↑bulk fiber
PSYCHOLOGICAL:
 Stress and relaxation techniques
MEDICATIONS:
 Loperamide (Imodium)
 Dicyclomine (Bentyl)
 Alosetron (Lotronex)
Lower GI Disorders
PROBLEM
DEFINITION:
Inflammation of the
appendix, a narrow blind
tube that extends from the
inferior part of the cecum.
(RIGHT LOWER QUAD)
Appendix- has no function
Appendicitis
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
Most common causes are:
 Obstruction of the lumen by a fecalith
(accumulated feces)
 Foreign bodies
 Tumor of the cecum or appendix
 Intramural thickening caused by
excessive growth of lymphoid tissue.
 Stricture
 Mucosal ulceration
 Edema / Impaired blood supply /
Hypoxia
 Obstruction results in distention, venous
engorgement, and the accumulation of
mucus and bacteria, which abscess can
rupture and can lead to gangrene and
perforation.
CLINICAL MANIFESTATIONS
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Symptoms vary and diagnosis can
be difficult.
Typically begins with
periumbilical pain
Followed by anorexia, nausea,
and vomiting.
Pain is persistent and continuous,
eventually shifting to the right
lower quadrant
Localizing at McBurney's point
(located halfway between the
umbilicus and the right iliac crest).
Abdomen localized tenderness,
rebound tenderness, and muscle
guarding.
Prefers to lie still, often with the
right leg flexed.
Low-grade fever may or may not
be present, and coughing
aggravates pain.
Rovsing's sign may be elicited by
palpation of the left lower
quadrant, causing pain to be felt
in the right lower quadrant.
ALERT: PAIN GOES AWAY MEANS
RUPTURE resulting in PERITONITIS
CAN BE FATAL
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COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
 WBC w/ Differential
o WBC count is mildly to
moderately elevated in
about 90% of cases
 Urinalysis
o Rule out UTI
 CT scan is preferred, but
ultrasound is also used
 Examination of the patient
includes a complete history and
physical examination
(particularly palpation of the
abdomen)
 Immediate surgical removal
 Antibiotic therapy and
parenteral fluids is given for 6 to
8 hours before the
appendectomy to prevent sepsis
and dehydration.
 SURGERY:
o Appendectomy
o Laparoscopic
 Laxatives and enemas are
especially dangerous because
the resulting increased
peristalsis may cause
perforation of the appendix
Lower GI Disorders
NURSING MANAGEMENT
ASSESSMENT:
SUBJECTIVE DATA:
 PAIN
OBJECTIVE DATA
Diagnostics
 WBC count with
Differential
 Urinalysis
 Abdominal X-Rays
 Abdominal Ultrasound
 Pelvic Examination
 CT scan
 IVP
 Pregnancy Test – ectopic
Pregnancy
Manifestations
 Board like Abdomen
 Rebound tenderness
 McBurney’s point
 Rovsings sign
Appendicitis
DIAGNOSIS
R/T Pain
R/T Infection
PLANNING - GOAL
INTERVENTIONS
RN role: Pre-op & Post-op
NPO
Ice bag may be applied to the right
lower quadrant to decrease
inflammation.
o Heat can cause the appendix to
rupture.
 Antibiotics and fluid resuscitation are
administered before surgery.
POST-OP
 Vital Signs
 Pain control
 Wound care
 Observe the patient for evidence of
peritonitis=Absent bowel sounds
 Ambulation begins the day of surgery or
the first postoperative day.
 Diet is advanced as tolerated



13
EVALUATION
Lower GI Disorders
PROBLEM
PERITONITIS
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
DEFINITION:
Results from a localized or
generalized inflammatory
process of the peritoneum.

Primary
 Blood-borne organisms enter the peritoneal
cavity
 Ascites (fluid) that occurs with cirrhosis of
the liver provides an excellent liquid
environment for bacteria to flourish
 Genital tract organisms
 Cirrhosis with ascites
Secondary – Abdominal organs perforate
 Appendicitis with rupture
 Blunt or penetrating trauma to abdominal
organs
 Diverticulitis with rupture
 Ischemic bowel disorders
 Pancreatitis
 Perforated intestine
 Perforated peptic ulcer
 Peritoneal dialysis
 Fistula opening into cavity
 Postoperative (breakage of anastomosis)

CLINICAL MANIFESTATIONS

Abdominal pain is the most common
symptom – Can be generalized or
local
 Universal sign of peritonitis is
tenderness over the involved area
 Rebound tenderness, muscular
rigidity, and spasm are other major
signs of irritation
 N/V
 Absent bowel sound
 Watch for signs of Hypovolemia
 ↓BP, ↑Temp, ↑HR, weak
thready pulse
 Distended Rigid board like
 Massive Infection
Complications
 hypovolemic shock
 sepsis
 intraabdominal abscess formation
 paralytic ileus
 acute respiratory distress syndrome.
Intestinal contents and bacteria irritate the
normally sterile peritoneum and produce an
initial chemical peritonitis that is followed a
few hours later by a bacterial peritonitis.
14
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES:
 CBC including WBC differential
 Serum electrolytes
 Abdominal x-ray
 Abdominal paracentesis and culture
of fluid
 CT scan or ultrasound
 Peritoneoscopy
COLLABORATIVE CARE
 Surgery is usually indicated to
drain purulent fluid and repair
damage.
 Other care includes antibiotics,
nasogastric suction, analgesics,
and intravenous (IV) fluid
administration.
Lower GI Disorders
NURSING MANAGEMENT



ASSESSMENT:
Assessment of the
patient’s abdominal pain
Pain, including the
location, is important
and may help in
determining the cause of
peritonitis.
Assess the patient for the
presence and quality of
bowel sounds, increasing
abdominal distention,
abdominal guarding,
nausea, fever, and
manifestations of
hypovolemic shock.
Knees flexed to increase
comfort
PERITONITIS
DIAGNOSIS
Acute pain related to
inflammation of the
peritoneum and abdominal
distention

Risk for deficient fluid
volume related to fluid
shifts into the peritoneal
cavity secondary to
trauma, infection, or
ischemia

Imbalanced nutrition:
less than body
requirements related to
anorexia, nausea, and
vomiting
Anxiety related to
uncertainty of cause or
outcome of condition
and pain

PLANNING - GOAL
Patient will:
 Resolution of
inflammation
 relief of abdominal pain
 freedom from
complications
(especially hypovolemic
shock)
 Normal nutritional
status.
INTERVENTIONS
Preoperative or Nonoperative
 NPO status
 IV fluid replacement
 Antibiotic therapy
 NG suction
 Analgesics (e.g., morphine)
 Anti-emetics
 Sedatives
 Low-flow Oxygen PRN
 Preparation for surgery to include the above
and parenteral nutrition
Postoperative
 NPO status (Rest Bowel)
 NG tube to low-intermittent suction
 Low flow oxygen
 Semi-Fowler's position
 IV fluids with electrolyte replacement
 Parenteral nutrition as needed
 Antibiotic therapy


15
Blood transfusions as needed
Sedatives and opioids
EVALUATION
Lower GI Disorders
PROBLEM
Inflammatory Bowel Disease
DEFINITION:
PATHOPHYSIOLOGY/ ETIOLOGY /RISK
FACTORS
Chronic inflammation of
the GI tract
 Characterized by periods
of remission interspersed
with periods of
exacerbation
 ↑ in seriousness the
greater the signs and
symptoms
 Since the cause is
unknown , Treatment
relies on medications to
treat the acute
inflammation and
maintain a remission.
 Crohn’s disease and
ulcerative colitis are
immunologically related
disorders that are referred
to as “inflammatory bowel
disease” (IBD).
Crohn's disease
 Inflammation of segments
of the GI tract (from
mouth to rectum)
Ulcerative colitis
 Inflammation and
ulceration of the colon and
rectum
PATHOPHYSIOLOGY
ULCERATIVE COLITIS:
 Diffuse inflammation beginning in the rectum
and spreading up the colon in a continuous
pattern.
 Starts in the rectum and goes to the colon.
 Multiple abscesses develop in the intestinal
glands and break through into the submucosa,
leaving ulcerations destroying the mucosal
epithelium, causing bleeding and diarrhea.
o Fluid and electrolyte losses
o Protein loss (Albumin ↓)
o Pseudopolyps develop.
 NO FISTULA, ABSCESS

CLINICAL MANIFESTATIONS
ETIOLOGY: Unknown
 Infections agent, autoimmune, emotional
stress, genetic
RISK FOR:
1st 15-35
2nd- 60-80
↑ Jewish, Caucasian females
16
ULCERATIVE COLITIS & CROHN’S
 Diarrhea, bloody stools, weight
loss, abdominal pain, fever, and
fatigue)
 Chronic disorders with mild to
severe acute exacerbations at
unpredictable intervals over
many years
ULCERATIVE COLITIS
 Bloody diarrhea and abdominal
pain.
o In severe will go up to 10-20
bloody stools per day
 Pain may vary from the mild lower
abdominal cramping associated
with diarrhea to the severe,
constant pain associated with
acute perforations
 Fever, weight loss greater than
10% of total body weight, anemia,
tachycardia, and dehydration are
present.
CROHN’S
 Diarrhea and colicky abdominal
pain
 If the small intestine is involved,
weight loss occurs from
malabsorption
 RECTAL BLEEDING sometimes
occurs with CROHN'S DISEASE
although not as often as with
ulcerative colitis.
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES
 Colonoscopy, Sigmoidoscopy
o Direct examination of the large
intestine mucosa. Since
ulcerative colitis usually begins
in the rectum, rectal biopsies
obtained during sigmoidoscopy
may be adequate for diagnosis
o Extent of inflammation,
ulcerations, pseudopolyps, and
strictures is determined, and
biopsy specimens are taken for
a definitive diagnosis
 Upper GI series
 Barium (double contrast)
o Shows granular inflammation
with ulcerations (U/C)
 Capsule Endoscopy (Crohn’s)
 Cultures
o C Diff. Rule out if left untreated
pseudomonas colitis
 Blood work
 H&H ↓Ulcerative colitis
Lower GI Disorders
PROBLEM
DEFINITION:
Crohn’s
Anywhere, everywhere, all
layers, slow & progressive
Inflammatory Bowel Disease
PATHOPHYSIOLOGY/ ETIOLOGY /RISK
FACTORS
CLINICAL MANIFESTATIONS
Pathophysiology
Crohn’s:
 Inflammation involves all layers of the bowel
wall.
 Inflammation spreads slowly and progressive
 Can occur anywhere in the GI tract from the
mouth to the anus,
o but occurs most commonly in the
terminal ileum and colon
 Segments of normal bowel can occur between
diseased portions, the so-called skip lesions
 Shallow ulcerations are deep and longitudinal
and penetrate between islands of inflamed
edematous mucosa, causing the classic
cobblestone appearance.
 Fibrosis (thickening) = Strictures (narrowing) at
the areas of inflammation = bowel obstruction.
 Inflammation goes through the entire wall,
 Microscopic leaks can allow bowel contents to
enter the peritoneal cavity = abscesses or
peritonitis.
o Perforation=Peritonitis=Absent bowel
sounds
o Massive Hemorrhage (sign & symptoms)
 May cause local bowel obstruction, abscess,
and fistula formation
o Abscesses or fistulous tracts that
communicate with other loops of bowel,
skin, bladder, rectum, or vagina may
occur.
o UTI 1st sign fistula
 Characterized by spontaneous remission
17
CROHN’S
 Diarrhea and colicky abdominal
pain
 If the small intestine is involved,
weight loss occurs from
malabsorption
 RECTAL BLEEDING sometimes
occurs with CROHN'S DISEASE
although not as often as with
ulcerative colitis.
Patients with Crohn's disease are more
likely to have a bowel obstruction,
fistulas, fissures, and abscesses.
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTIC STUDIES
 CBC typically shows iron-deficiency
anemia from blood loss.
 ↑WBC count may be an indication
of toxic megacolon or perforation.
 ↓in serum Na, K, Cl, bicarbonate,
and Mg levels r/t fluid and
electrolyte losses from diarrhea
and vomiting.
 Hypoalbuminemia is present with
severe disease and is the result of
poor nutrition or protein loss from
the bowel.
 ↑erythrocyte sedimentation rate
reflects chronic inflammation.
 Stool cultures for infection

Asses stool for blood, pus, and
mucus
COLLABORATIVE CARE
SURGERY
Crohn's Disease
 Bowel Resection
o Removal of diseased portion
o Anastomosis (re-attatch)
 Ostomy anywhere
Ulcerative Colitis
 Ileostomy
o Liquid stool/Right Side
 Kock's ileostomy
o Continent ileostomy
 Ileoanal reservoir
o procedure involves total
colectomy and ileoanal
anastomosis with the
formation of an ileal reservoir
Lower GI Disorders
NURSING MANAGEMENT
ASSESSMENT:
Ulcerative Colitis
Crohn's Disease






Diarrhea
Bloody stool
Fatigue
Abdominal pain
Weight loss
Fever
ULCERATIVE COLITIS:
Major symptoms
 Bloody diarrhea
 Abdominal pain
Other symptoms
 Tenesmus (contraction of
sphincter spasms w/ pain)
 Rectal bleeding
 Blood Loss
CROHN’S DISEASE:
 Diarrhea
 Colicky abdominal pain
 Weight loss may occur if
small intestine is involved
 RLQ tenderness relived
after BM
Inflammatory Bowel Disease
MEDICATIONS
Dependent:
IBD MEDICATIONS
Sulfasalazine (Azulfidine)
 Sulfapyridine and 5-ASA
 Decreases GI inflammation
 Effective in achieving and
maintaining remission
 Mild to moderately severe
attacks
Corticosteroids
 Decrease inflammation
 Used to achieve remission
 Helpful for acute flare-ups
Immunosuppressants
 Maintain remission after
corticosteroid induction
therapy
 Require regular CBC
monitoring
Biologic therapies
 Anti-TNF agents
 Infliximab (Remicade)
 Adalimumab (Humira)
Antimicrobials
Anti-diarrheal
Antiemetics
DIAGNOSIS/PLANNING - GOAL




Diarrhea related to bowel
inflammation and intestinal
hyperactivity
Imbalanced nutrition: less than
body requirements
Anxiety related to possible
social embarrassment
Ineffective coping related to
chronic disease
INTERVENTIONS




Focus is effective management of
disease with avoidance of
Complications












rest the bowel
control the inflammation
combat infection
correct malnutrition
alleviate any stress
provide symptomatic relief
experience a decrease in
number and severity of acute
exacerbations
maintain normal fluid and
electrolyte balance,
be free from pain or discomfort
comply with medical regimens,
maintain nutritional balance,
Have improved quality of life.
18



DIET
High-calorie, high-vitamin, high-protein,
low-residue, lactose-free (if lactase
deficiency) diet
B12
o Terminal ileum is involved in Crohn's
disease there is reduced absorption
of Cobalamin, contributing to
anemia.
Parenteral nutrition allows for a positive
nitrogen balance while resting the bowel,
but enteral feedings are preferred
because of their effects on the colonic
microflora.
Stress management
o Recognize that the patient's behavior
may result from factors other than
emotional distress.
o A person who has 10 to 20 bowel
movements a day, rectal discomfort,
and an unpredictable disease is likely
to be anxious, frustrated,
discouraged, and depressed.
Rest is important.
o Patients suffer severe fatigue, which
limits energy for physical activity.
Keep clean, dry, and free of odor.
TEACHING
(1) Importance of rest and diet
management,
(2) Perianal and Ostomy care,
(3) Action and side effects of drugs,
(4) symptoms of recurrence of disease,
(5) When to seek medical care,
(6) Use of diversional activities to reduce
stress.
EVALUATION
Lower GI Disorders
PROBLEM
DEFINITION:




Third most common form
of cancer and the second
leading cause of cancerrelated deaths in the
United States.
CRC has an insidious
onset, and symptoms do
not appear until the
disease is advanced.
Regular screening is
necessary to detect
precancerous lesions.
Approximately 85% of
CRCs arise from
adenomatous polyps,
Can be detected and
removed by
sigmoidoscopy or
colonoscopy
Colorectal Cancer
PATHOPHYSIOLOGY/ ETIOLOGY
RISK FACTORS
PATHOPHYSIOLOGY
 Begins as adenomatous polyps. As it
grows, the cancer invades and
penetrates the muscularis mucosae
 Tumor cells gain access lymphatic and
vascular system, and spread to distant
sites.
 Liver is a common site of metastasis
 Metastasis (cancer spreads) from the
liver to the lungs, bones, and brain.
 Complications
o Obstruction, bleeding, perforation,
peritonitis, and fistula formation.
ETIOLOGY
 ↑men
 mortality rates are ↑African American
men and women
 90% of new CRC cases are detected in
people older than 50
RISK FACTORS
 increasing age,
 family or personal history of CRC
 colorectal polyps
 IBD
 Obesity (body mass index ≥30 kg/m2)
 Red meat (≥7 servings/wk)
 Processed food
 Cigarette use
 Alcohol (≥4 drinks/wk)
CLINICAL MANIFESTATIONS
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
Usually nonspecific
Do not appear until the disease is
advanced (LATE DIAGNOSIS)
Left side
 Rectal Bleeding/ Blood in stool
 Left-sided lesions
 Constipation and diarrhea
 Stool caliber (narrow, ribbonlike)
 Sensation of incomplete evacuation.
 Obstruction symptoms appear earlier with
left-sided lesions.
Right side
 Asymptomatic
 Vague abdominal discomfort or cramping,
colicky abdominal pain
 Iron-deficiency anemia
 occult bleeding lead to weakness and
fatigue.
DIAGNOSTIC
 Digital rectal examination
 Testing of stool for occult blood
 Barium enema (5 years)
 Sigmoidoscopy (5 years)
 Colonoscopy (10 years)
o Gold standard for CRC screening
o Age 50 (African Amer. @ 45)
o Removal of polyps / biopsy
 CBC
 Liver function tests
 CT scan of abdomen
 MRI •Metastasis
 Ultrasound
 Chest x-ray • Metastasis
 Carcinoembryonic antigen (CEA) test
COLLABORATIVE CARE
SURGERY site of the CRC dictates the
site of the resection
o Right hemicolectomy
o Left hemicolectomy
o Abdominal-perineal resection
o Laparoscopic colectomy
 Ascending Colostomy
 Transverse Colostomy
 Descending Colostomy
 Sigmoid Colostomy
 Radiation
 Chemotherapy
 Biologic and targeted therapy


19
Lower GI Disorders
NURSING MANAGEMENT
Colorectal Cancer
ASSESSMENT:
Subjective Data
Important Health Information
Past health history: Previous breast or ovarian
cancer, familial polyposis, villous adenoma,
adenomatous polyps, inflammatory bowel disease
Functional Health Patterns
Nutritional-metabolic: High-calorie, high-fat, lowfiber diet; anorexia, weight loss; nausea and vomiting
Elimination: Change in bowel habits; alternating
diarrhea and constipation, defecation urgency; rectal
bleeding; mucoid stools; black, tarry stools; increased
flatus, decrease in stool caliber; feelings of
incomplete evacuation
Cognitive-perceptual: Abdominal and low back pain,
tenesmus
Objective Data
Pallor, cachexia, lymphadenopathy (later signs)
Gastrointestinal
Palpable abdominal mass, distention, ascites, and
hepatomegaly (liver metastasis)


DIAGNOSIS
PLANNING - GOAL
Knowledge
deficit
Sexual
dysfunction

Focus is on early
detection and
intervention
Possible Diagnostic Findings
Anemia; guaiac-positive stools, palpable mass on
digital rectal examination; positive sigmoidoscopy,
colonoscopy, barium enema, or CT scan; positive
biopsy
Metastasis commonly occur in the liver
Medications: Cytotoxics = doxorubicin (Adriamycin),
5-fluorouracil (Adrucil)
Antiemetics: Zofran
Analgesics: morphine, hydromorphone (Dilaudid)
20
INTERVENTIONS

Diet
o No High Fat, red meat, processed
food.
o Increase fiber Fruit & veg
 Screening
o Over 50 to have regular CRC
screening. 40 digital Exam
o High-risk patients should begin @ 45,
usually beginning with colonoscopy
 Medical Attention (Blood in Stool call Dr.)
 Lower Risk (Aspirin NSAIDs ↓ risk)
Preoperative care
 Inform patients about prognosis and
future screening
 Support
Postoperative care
 Sterile dressing changes, care of drains,
 Assess all drainage for amount, color, and
consistency (serosanguineous)
 Patient and caregiver education about the
stoma. (Pink & Moist)
 Wound and ostomy care nurse should be
consulted about care.
 Signs and symptoms of wound
inflammation and infection
 Monitor for edema, erythema, and
drainage around the suture line, as well as
fever and an elevated WBC count
 Address sexual dysfunction concerns
 Emotional and Group support
 Ostomy care
 Diet, incontinence products, and
strategies for managing bloating, diarrhea,
and bowel evacuation.





EVALUATION
Minimal
alterations in
bowel
elimination
patterns
Relief of pain
Balanced
nutritional
intake
Quality of life
appropriate
to disease
progression
Feelings of
comfort and
well-being
Lower GI Disorders
PROBLEM
DEFINITION:




Small
Intestinal
Obstruction
Large
Intestinal
Obstruction
Obstruction =
Blockage
Obstructions
may be partial
or complete.
Intestinal Obstruction = Blockage
PATHOPHYSIOLOGY/ ETIOLOGY / RISK FACTORS
CLINICAL MANIFESTATIONS
Pathophysiology
 Mechanical
o Foreign Bodies, Object, Tumor, Adhesion (Scar Tissue)
o Detectable occlusion of the intestinal lumen. Most intestinal
obstructions occur in the small intestine
 Functional
o Spinal Cord Injury, poor functioning peristalsis, post-op
paralytic ileus
o Neuromuscular or vascular disorder.
o Vascular disorders are due to interference in the blood
supply to the intestine.
 Fluid, gas, and intestinal contents accumulate proximally and
the distal bowel collapses
 Increased pressure leads to an increase in capillary permeability
and extravasation of fluids and electrolytes into the peritoneal
cavity. Retention of fluids in the intestine and peritoneal cavity
leads to a severe reduction in circulating blood volume and
results in hypotension and hypovolemic shock
Causes of Mechanical Obstructions
 Adhesions (scar tissue)
 Strangulated inguinal hernia
 Ileocecal intussusception
 Intussusception from polyps (inverts in itself)
 Mesenteric occlusion
 Neoplasm
 Volvulus (twisting) of the sigmoid colon
o At risk for dead colon
Causes of Functional Obstructions
 Spinal Cord Injury
 Poor functioning peristalsis
 Paralytic ileus (Post-op)
o Lack of intestinal peristalsis and the presence of no bowel
sounds
 Emboli
21
Vary, depending on the location of the
obstruction, Include:
 Nausea
 Vomiting,
 Poorly localized abdominal pain
 Abdominal distention,
 Inability to pass flatus,
 Obstipation
 Signs and symptoms of hypovolemia
 Characteristic sign of mechanical
obstruction is pain that comes and
goes in waves
Small Intestine:
 Rapid Onset
 Vomiting: Frequent and copious
o Proximal: projectile in
nature and contains bile
o Distal: more gradual in
onset. vomitus may be
orange-brown and foul
smelling like feces
 Pain: Colicky, cramplike,
intermittent
 Feces for a short time
 Abdominal distention Greatly
increased
Large Intestine:
 Gradual Onset
 Vomiting Rare
 Pain: Low-grade, cramping
abdominal pain
 Absolute constipation
 Abdominal distention Increased
COLLABORATIVE CARE /
DIAGNOSTIC STUDIES:
DIAGNOSTICS
 Abdominal X-rays & CT
Scans
 Blood work
o WBC ↑
o H&H (↓bleeding from a
neoplasm or
strangulation with
necrosis)
(↑hemoconcentration)
o Serum electrolytes,
BUN, and creatinine
(monitor hydration)
o Metabolic alkalosis
(vomit)
 Barium Enema
 Colonoscopy &
Sigmoidoscopy
 Occult blood
COLLABORATIVE CARE
 Emergency surgery is
performed if the bowel is
strangulated,
 Many bowel obstructions
resolve with conservative
treatment.
 Surgery to remove
obstruction if not resolved
on it’s own
Lower GI Disorders
NURSING MANAGEMENT
ASSESSMENT:
Subjective:
Pain, Nausea Vomit
Objective :
 Auscultation of bowel
sounds reveals highpitched sounds above
the area of obstruction.
 Bowel sounds may also
be absent.
 Borborygmi (audible
abdominal sounds
produced by hyperactive
intestinal motility).
 Temperature rarely rises
above 100° F unless
strangulation or
peritonitis has occurred.
Intestinal Obstruction



DIAGNOSIS
Acute pain
Deficient fluid volume
Imbalanced nutrition




PLANNING - GOAL
Relieving Pressure and
Obstruction
Supportive Care
Minimal to no discomfort
Normal fluid and
electrolyte and acid-base
status.
22
INTERVENTIONS
Treatment
 NG tube
o Gastrointestinal Decompression
o Care for NG
o Check the NG tube every 4 hours for
patency
 Surgery
 NPO = Rest bowel
 Assess allergies before tests
 Monitor the patient closely for signs of
dehydration and electrolyte imbalances.
 Administer IV fluids as ordered.
 Monitor serum electrolyte levels
closely.
 High intestinal obstruction is more likely
to have metabolic alkalosis r/t vomit
 Low obstruction is at greater risk of
metabolic acidosis.
 Provide comfort measures and promote
a restful environment
 Oral care is extremely important
EVALUATION
Lower GI Disorders
PROBLEM
Diverticula Hernias
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
DEFINITION:
Diverticula
 Saccular dilations or
outpouchings of the
mucosa that develop
in the colon at points
where the vasa recta
penetrate the circular
muscle layer
.
 Diverticula may occur
at any point within
the GI tract but are
most commonly
found in the sigmoid
colon.






Multiple noninflamed diverticula =
diverticulosis.
Diverticulitis = inflammation of the
diverticula, → perforation into the
peritoneum.
Diverticular disease is common and its
incidence increases with age
Etiology of diverticulosis of the ascending
colon is unknown,
Low Fiber diet, can be a cause
Disease is more prevalent in Western,
consume diets low in fiber and high in
refined carbohydrates and is uncommon in
vegetarians
Hemorrhoids
CLINICAL MANIFESTATIONS
Diverticulosis
 Asymptomatic
Diverticulitis in the sigmoid colon
 LLQ abdominal pain
 Abdominal pain is localized over the
involved area of the colon
 sometimes fever
 ↑WBC leukocytosis,
 Palpable abdominal mass.
 Relief from BM
 N/V
 Complications such as perforation,
abscess, fistula, and bleeding
 Elderly patients with diverticulitis may be
afebrile, with a normal WBC count and
little, if any, abdominal tenderness.
23
COLLABORATIVE CARE / DIAGNOSTIC
STUDIES:
DIAGNOSTIC STUDIES:
CT scan with oral contrast.
COLLABORATIVE CARE
Teach Patients:
 High-fiber diet, mainly from fruits and
vegetables, and decreased intake of
fat and red meat are recommended
for preventing diverticular disease.
NO NUTS OR SEEDS
 High levels of physical activity also
seem to decrease the risk.
 High-fiber diet
 Dietary fiber supplements
 Stool softeners
 Anticholinergics
 Mineral oil
 Bed rest
 Clear liquid diet
 Oral antibiotics
 Bulk laxatives
 Weight reduction (if overweight)
 Increased intraabdominal pressure
should be avoided
Diverticulitis
 Antibiotic therapy
 NPO status=Let colon rest
 IV fluids
 Possible resection of involved colon
for obstruction or hemorrhage
 Possible temporary colostomy
 Bed rest
 NG suction
Lower GI Disorders
PROBLEM
Diverticula Hernias
Hemorrhoids
DEFINITION:
PATHOPHYSIOLOGY/ ETIOLOGY / RISK
FACTORS
CLINICAL MANIFESTATIONS
COLLABORATIVE CARE / DIAGNOSTIC
STUDIES:
HERNIAS
 Protrusion of a viscus
through an
abdominal opening
or a weakened area
in the wall of the
cavity in which it is
normally contained.
HERNIAS
 Inguinal hernia is the most common type
of hernia and occurs at the point of
weakness in the abdominal wall where the
spermatic cord in men and the round
ligament in women emerge
 Femoral hernia occurs when there is a
protrusion through the femoral ring into
the femoral canal.
 Umbilical hernia rectus muscle is weak (as
with obesity) or the umbilical opening fails
to close after birth.
HERNIAS
 Readily visible, especially when the person
tenses the abdominal muscles.
 discomfort as a result of tension
 Nausea, vomiting, abdominal distention
and tenderness.
 Hernia becomes strangulated; the patient
will have severe pain and symptoms of a
bowel obstruction such as vomiting,
cramping abdominal pain, and distention.
HERNIAS
Diagnosis is based on history and physical
examination findings
COLLABORATIVE CARE
 Nursing intervention= teach No
valsalva maneuver, no heavy lifting,
avoid coughing
 Surgery is the treatment of choice for
hernias and prevents strangulation.
 Treatment of hernias is by
laparoscopic surgery.
 Patient may have difficulty
voiding. You should observe for a
distended bladder
 Restricted from heavy lifting for 6
to 8 weeks
HEMORRHOIDS
 Supporting tissues in the anal canal
weaken, usually as a result of straining at
defecation, venules become dilated.
RISK FACTORS:
 Pregnancy
 prolonged constipation
 straining in an effort to defecate
 heavy lifting
 prolonged standing and sitting
 portal hypertension (as found in cirrhosis).
 Obesity
HEMORRHOIDS
 Most common reason for bleeding with
defecation.
 The amount of blood lost at one time may
be small but over time may lead to irondeficiency anemia
 Internal: Patient may report a chronic, dull,
aching discomfort, particularly when the
hemorrhoids have prolapsed.
 External hemorrhoids : cause intermittent
pain, pain on palpation, itching, and
burning.
 Bleeding associated with defecation.
 Constipation or diarrhea can aggravate
these symptoms.


Reducible =able to be
pushed back into the
abdominal cavity
Incarcerated= unable
push back in into the
abdominal cavity
HEMORRHOIDS
 Dilated hemorrhoidal
veins.
 Internal (occurring
above the internal
sphincter)
 External (occurring
outside the external
sphincter)
S/S:
Anal pain with
defecation, sitting,
or walking.
Anal Pruritus
Prolapse of rectal
mucosa.
Surgical Interventions: Stapled hemorrhoid
surgery, or Barron rubber-band ligation.
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HEMORRHOIDS
DIAGNOSTIC:
Internal hemorrhoids
 Digital examination, Anoscopy, and
sigmoidoscopy.
External hemorrhoids
 Visual inspection and digital
examination
COLLABORATIVE CARE
 Sitz baths, witch hazel compresses
 Position: side-lying or prone
 No straining
 Stool softener (Colace)
 ↑ Fiber & water, High residue diet
Post-op
 Pain med (Tylenol)
 Assess for rectal bleeding and
Incontinence High Risk
Lower GI Disorders
OSTOMY CARE & SITES
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Assessment (assess and document stoma appearance, pts psychologic preparation for ostomy care,
Chose appropriate ostomy pouching system
Develop plan of care for skin around the Ostomy
Teach caregiver and educate pt. about appropriate diet, irrigate new colostomy.
Should look pink and moist
Changing the appliance
Irrigation 500-1000ml lukewarm water in container, ensure comfortable position, clear tubing of all air by flushing it w liquid, hang container on hook, apply
irrigating sleeve and place bottom end in toilet bowel, lubricate stoma cone and insert cone tip gently into the stoma, allow irrigation solution to flow 5-10 mins, if
cramping occurs stop flow of solution for a few seconds, clamp the tubing and remove irrigating cone when desired amount has been delivered, allow 30-45 mins
for solution and feces to be expelled, clean rinse and dry peristomal skin well, replace the colostomy drainage pouch and stoma covering, wash and rinse all
equipment and hang to dry.
Colostomy irrigations may be used to stimulate emptying of the colon. Prevent constipation, because ↓ in peristalsis
When the colon is irrigated and emptied on a regular basis, no stool is eliminated between irrigation sessions.
Irrigation requires manual dexterity and adequate vision.
However, if bowel control is achieved, there should be little or no spillage between irrigations, and the patient may need to wear only a pad or small pouch over the
stoma.
Regularity is only possible when the stoma is in the distal colon or rectum.
Irrigation is not used for more proximal ostomies.
People who irrigate regularly should still have ostomy bags readily available in case they develop diarrhea from foods or illness.
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