Medical Surgical Nursing
Gastrointestinal System
- Gastroesophageal Reflux Disease
-Gastroenteritis
-Constipation
-Hemorrhoids
-Diarrhea
Anatomy of Gastrointestinal system
The GI System
 Tube approximately 30 feet ( 9 meter) long from mouth to the
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anus.
Innervated by parasympathetic ( excitatory) and sympathetic
nervous system (inhibitory) of the ANS.
Enteric Nervous system – GI tract own nervous system that
contains numerous neurons and has the ability to control
movement and secretion of the GI tract.
Two types of movements of the GI tract – mixing (segmentation)
and propulsion (peristalsis).
Blood Supply- Upper GI receives blood from
Splanchnic artery.
Blood draining the GI tract empties into the
portal vein, then perfuse to liver.
Small intestine receives from hepatic and
superior mesenteric arteries.
Large intestine receives from superior and inferior
mesenteric arteries.
The GI System
 Secretions of GI systems – enzymes, hormones for
digestions, mucus to provide protection and
lubrication, and water and electrolytes.
 Physiology (Functions)
- Ingestion and Propulsion of food (Mouth,
Pharynx and Esophagus).
- Digestion and Absorption (Mouth, Stomach, Small
Intestine)
- Elimination (Large Intestine)
GI System Physiology
 Ingestion and Propulsion of food- intake of food.
Saliva is use for food lubrication.
Mechanical breakdown of food.
 Digestion – begins in the mouth, in the stomach the
digestion of protein begins with the
release of pepsinogen turn to pepsin.
-Food stay in the stomach 3-4 hours.
- When food enters stomach and small
intestine,hormones are release into the
bloodstream.
- Digestion is complete at the small
intestine. Bile is necessarry for digestion of
fats.
- Cholecystokinin – stimulates pancrease to
synthesize and secretes enzymes for digestion of
carbohydrates, fats and protein.
GI System Physiology
 Digestion – Enzyme present at the microvilli
completes digestion process. These
enzymes hydrolyze disaccharides to
monosaccharides and peptides to amino
acids for absorption.
 Elimination – large intestine is responsible for
absorption of water and electrolytes.
Large intestine also serve as reservoir for
fecal mass until defecation occurs.
Defecation is a reflex action involving
voluntary and involuntary control.
Defecation can be facilitated by Valsalva
Maneuver. This maneuver involves contracation
of the chest muscles on a close glottis with
simultaneous contraction of the abdominal
muscle.
GI System Physiology
 Valsalva Maneuver increases intraabdominal
pressure. Maybe contraindicated in a client
with head injury, eye surgery, cardiac
problems, hemorrhoids, abdominal
surgery,or liver cirrhosis.
 Constipation – is common in the older adult and is
due to many factors including slower peristalsis,
inactivity, decreased dietary fibers, decreased fluids,
depression, constipating medications, and laxative
abuse.
GI Secretions Related to Digestion
page 929
 Salivary Glands – Salivary amylase, Pepsinogen
 Stomach-
HCl acid, Lipase, Intrinsic Factor
 Small Intestine - Enterokinase, Amylase, Peptidases,
Aminopeptidases, Maltase, Sucrase,
Lactase, Lipase
 Pancrease Trypsinogen, Chymotrypsin,
Amylase, Lipase
 Liver and Gallbladder - Bile
Factors that affects the GI System Functioning
 Main function – supply nutrients to body cells.
 Factors outside GI system can influence its functioning e.g.
stress and anxiety.
 Stress can be experienced as anorexia, epigastric pain and
abdominal pain.
 Physical factors that affect GI functioning includes dietary
intake, ingestion of alcohol and caffeine containing
products, cigarette smoking, poor sleep, and fatigue.
Gerontologic Considerations : Effects of Aging on the GI
System.
Expected Aging Changes:
Mouth – Gingival Retraction
Decreased taste buds
Decrease volume of saliva
Atrophy of gingival tissue
Esophagus – Decreased esophageal sphincter pressure,
Motility decreased.
Abdominal Wall – Thinner and less taut.
Decrease in number and sensitivity
of sensory receptors.
Gerontologic Considerations : Effects of Aging on the GI
System.
 Stomach – Atrophy of gastric mucosa, decrease in
blood flow.
 Small Intestine- Slight decrease in secretion of most
digestive enzymes and motility.
 Liver – Decrease size and lowered in position.
Decrease in protein synthesis, ability to
regenerate decreased.
 Large Intestine, Anus, Rectum – Decreased anal
sphincter tone and nerve supply to rectal area
Decrease muscular tone, decreased motility,
Increase in transit time, sensation to defecation
decreased.
Gerontologic Considerations : Effects of Aging on the GI
System.
 Pancreas – Pancreatic duct distended, lipased
production decrease, pacreatic reserve
impaired.
Differences in Assessment Findings:
 Loss of teeth, presence of dentures, diminish sense of
taste.
 Dry oral mucosa.
 Epigastic distress, dysphagia, potential for hiatal
hernia and aspiration.
 Food intolerances, signs of anemia resulting from
cobalamin malabsorption, decreased gastric emptying.
 Complaints of indigestion, slowed intestinal transit.
Gerontologic Considerations : Effects of Aging on the GI
System.
Differences in Assessment Findings: Cont.
 Delayed absorption of fat-soluble vitamins.
 Liver is easier to palpate due to lower border.
 Liver - Decrease in drug metabolism.
 Fecal Incontinence
 Flatulence, abdominal distention, relaxed perineal
musculature, constipation, fecal impaction.
 Impaired fat absorption, decreased glucose tolerance.
Factors that determine whether GERD is present
 Efficiency of antireflux mechanism
 Volume of gastric contents
 Potency of refluxed material
 Effeciency of esophageal clearance
 Resistance of the esophageal tissue to injury and the
abilityn to repair tissue
The client must have several episodes of reflux for
GERD to be present.
Assessment: Functional health Patterns Table 39-8
 Health perception- health management Patterns:
- Nurse should ask about health practices related to GI
system e.g maintenace of normal body weight.
 Nutritional Metabolic Patterns:
- Dietary history should be taken and compared with
the food pyramid.
 Elimination Patterns:
-Client should be asked on the frequency, time of day,
and usual consistency of stool should be noted.
 Activity –Exercise Patterns.
- The pt. ambulatory status should be checked.
Assessment: Functional health Patterns Table 39-8
 Sleep-rest Patterns:
- The pt. should be asked if GI symptoms affects sleep
or rest.
 Cognitive-Perceptual Patterns:
- The pt. should be assess with sensory adequacy,
change in smell or taste. Pain should also be assessed.
 Self-Perception/Self-Concept Pattern:
- Assess the pt’s willingness to engage in self-care and
to discuss this situation.
Assessment:Functional Health Patterns Tbl: 39-8
 Role-Relationship Pattern:
- Assess availability of and satisfaction with support.
 Sexuality- reproductive Pattern:
- Assess for effect of problems related to GI on pt’s
sexuality and reproductive status.
 Coping-Stress Tolerance Pattern;
- Determine what is the stressor for the pt. and what
coping mechanisms the pt. uses to function with
these stressors.
 Value-Belief Pattern:
Pt’s spiritual and cultural beliefs regarding food
preparation should be assessed.
Different Diets for GI System Disorders
 Diet for constipation –High Fiber diet e.g.
Raw Fruits and Fruit juices esp. prune and
grape juice, raw vegetables, cabbage, sweets,
alcohol and highly spicy foods stimulates
stool production.
 Foods that can contribute fecal incontinence
e.g. chocolate, coffee, tea, and other
caffeinated beverages stimulates the anal
sphincters to relax .
 Food that can thickened stool e.g.
bananas, rice, bread, potatoes, cheese, yogurt,
oatmeal, oatbran, boiled milk and pasta.
Different Diets for GI System Disorders
 Odor-causing foods include cabbage family vegetables,
beans, garlic, eggs, fish, and turnips.
 Gas –producing foods include beans, beer, carbonated
beverages, cucumbers, cabbage, broccoli, dairy
products and corn.
 Ileostomy diet – avoid excess gas, maintain a soft
stool, and avoid obstruction of the catheter. Pt should
avoid: coffee, alcohol, and gas forming foods, skins,
seeds and nuts including corn, olives and peas,
pineapple, berries, fresh fruits, milk products is cause
excessive gas.
Different Diets for GI System Disorders
 Diet for Peptic Ulcer – permit the client almost any foods
that do not produce discomfort.
- Avoid foods that stimulate acid secretions but do not
neutralize acids.
- Foods include coffee, tea, meat broth, and alcohol.
 Lactose Intolerance – Avoid milk and milk products. Use
soymilk products.
- Restricting milk may result in Calcium , riboflavin and
Vit. D deficiency.
 Gluten-Free Diet - diet completely free of ingredients
derived from gluten-containing cereals/ wheat, barley, rye,
Malts , as well as the use of gluten as a food additive in the
form of a flavoring, stabilizing or thickening agent. It is the
only medically accepted treatment for celiac disease and
wheat allergy.
Different Diets for GI System Disorders
 Low residue diet is a special diet, which is low in fiber and high
in other dietary elements.
 The low residue diet is used as a preparation for certain medical
examinations as well as an aid to cure certain health problems.
The low residual diet is thus prescribed under certain special
conditions only.
 The low residue diet contains less than 10-15 grams of fiber per
day.
What does the low residue diet aim at?
Basically, by lowering the dietary fiber contents, the low residue
diet is designed to reduce the frequency and volume of the
stools. The low residue diet helps to prolong the intestinal transit
time. Simply, the low residue diet aims to reduce the bowel
activity.
Gastrointestinal Disorders
 GERD
 PUD
 Gastroenteritis
 Constipation
 Diarrhea
 Inflammatory Bowel Diseases
 Colorectal Cancer
 Hemorrhoids
Gastroesophageal Reflux Disease (GERD)
 GERD – results of an incompetent lower esophageal
sphincter that allows regurgitation of acidic gastric
contents into the esophagus.
 Condition characterized by gastric contents and enzyme
leakage into esophagus.
 Corrosive fluids (stomach acid)irritate the esophageal
tissue and limit its ability to clear the esophagus.
 Causes prolonged or frequent transiet relaxation of the
lower esophageal sphincter (LES) at the base of the
esophagus, or delayed gastric emptying.
Symptoms of GERD
 Frequent and prolonged retrosternal heartburn
(dyspepsia) and regurgitation (acid reflux) in
relation to eating or activities.
 Chronic cough
 Dysphagia
 Belching ( eructation)
 Flatulence (gas)
 Atypical chest pain
 Asthma exacerbation.
GERD
Nursing Assessment of GERD
 Heartburn after eating
 Feeling of fullness and discomfort after eating
 Positive diagnosis determined by fluoroscopy or Barium Swallow.
Fluoroscopy is a type of medical imaging that shows a
continuous x-ray image on a monitor, much like an xray movie. It is used to diagnose or treat patients by
displaying the movement of a body part or of an
instrument or dye (contrast agent) through the body.
During a fluoroscopy procedure, an x-ray beam is
passed through the body. The image is transmitted to a
monitor so that the body part and its motion can be
seen in detail.
Etiology (Cause) of GERD
 Any factor that relaxes the LES such as:
SMOKING
CAFFEINE
ALCOHOL
DRUGS
 Any factor that increases the abdominal pressure:
OBESITY
TIGHT CLOTHING AT THE WAIST
ASCITES
PREGNANCY
 OLDER AGE and/or debilitating condition that weakens
the LES tone.
Contributing Factor
 Diet: Excessive ingestion of foods that relaxes the
LES.
- Fatty and fried foods
- Chocolate
- Caffeinated beverages such as coffee
- Peppermint
- Spicy foods
- Tomatoes
- Citrus foods
- Alcohol
Contributing Factors
 Distended abdomen from overeating or delayed
emptying.
 Increased abdominal pressure e.g. ascites, obesity,
pregnancy, bending at the waist, tight clothing at the
waist.
 DRUGS that relaxes the LES e.g. Theophylline,
Nitrates, Calcium Channel Blockers, anticholenergics,
and Diazepam.
 Drugs such as NSAIDS, or events like stress that
increase gastric acid.
Contributing Factors
 Debilitation or age related conditions resulting in
weakened LES tone.
 Hiatal Hernia – herniation of the esophagogastric
junction and the portion of the stomach into the chest
through the esophageal hiatus of the diaphragm.
Hiatal Hernia –LES displacement into the thorax with
delayed esophageal clearance.
 Lying flat
Diagnostic Procedures for GERD and Nsg.
Interventions
 Hx : Symptoms 4 to 5 times per week on a
consistent basis
 Improvement after a 6 week-course of Proton pump
inhibitors (PPI) main action is a pronounced and longlasting reduction of gastric acid production e.g. Omeprazole
(Prilosec) , Lansoprazole (Prevacid), Pantoprazole (Protonix).
 Barium Upper GI : Pre-Procedure: Fiber diet for 2-3
days before the barium swallow test. You will be asked not
to eat or smoke after midnight before the exam. Post
procedure: assess for BS and potential constipation.
 Endoscopy – pt. under conscious sedation to observe
for tissue damage.
 Esophageal Manometry – used to measure muscle
tone of LES and pH monitoring.
Esophageal Manometry
 The exam is often done before and after
medical or surgical treatment of the
esophagus. Esophageal manometry is
very effective in evaluating the
contraction function of the esophagus
in many situations.
 Manometry is the recording of muscle
pressures within an organ. So
esophageal manometry measures the
pressure within the esophagus. It can
evaluate the action of the stripping
muscle waves in the main portion of the
esophagus as well as the muscle valve at
the end of it.
Therapeutic Interventions
 Surgery (Fundoplication) - surgeon wraps the fundus
of the stomach around and behind the esophagus through
laparoscopy to create a physical barrier.
Nursing Interventions
 Assessments
-Monitor for sign and symptoms – classic
sign: Dyspepsia especially after eating.
chronic cough from irritation,
hypersalivation, eructation, flatulence, ,
atypical chest pain,
Assessment
 Assess client’s dietary intake pattern. Attention to food
containing caffeine and fat.
 Smoking history.
 Alcohol use.
 Weight
NANDA Nursing Diagnosis
 Acute pain
 Deficient knowledge
 Anxiety
Nursing Plans and Interventions
 Determine eating patterns that alleviates symptoms:
1. Encourage small frequent meals.
2. Encourage elimination of foods that are determined to
3.
aggravate symptoms.
Encourage client to sit up while eating and remain in an
upright position for at least an hour after eating.
A fowler or semi-fowler position is beneficial in reducing the
amount of regurgitation as well as in preventing the
encroachment of the stomach upward through the opening of
the diaphragm.
4. Encourage client to stop eating three hours before bedtime.
5. Teach about commonly prescribed medications ( H2 antagonist,
antacids).
Teaching Plans for client and family
 Differentiate between the symptoms of hiatal hernia and
those of MI.
 Alert to the possibility of aspirations.
 Diet – avoid offending foods
avoid large meals
remain upright after eating
avoid eating before going to bed.
 Lifestyle – avoid tight fitting clothing
Lose weight if applicable.
Elevate the head of the bed with blocks.
Use of pillow is not recommended as this
rounds the back, bringing the stomach
contents up closer to the chest.
Medications
 Antacids – e.g. Mylanta Neutralize excess acids.
administer 1-3 hours after eating and at HS.
Should be separated with other meds at
least 1 hour.
 Histamine 2 receptor antagonist – e.g. Zantac
(Ranitidine). Reduce the secretion of acid.
 Proton Pump Inhibitors (PPIs) – e.g Protonix
(Pantoprazole).
 Reglan (Metochlopramide HCL) to increase motility of
the esophagus and stomach.
Complications
 Aspiration
 Asthma exacerbation
 Frequent URI, sinus or ear infections.
 Aspiration pneumonia
 Esophageal stricture (scarring)
 Erosive esophagitis (ulceration and hemorrage).
 Barrett’s epithelium (premalignant) and esophageal
carcinoma.
Peptic Ulcer Disease
 Ulceration that penetrates the mucosal wall of the GI
tract.
 Gastric Ulcer- occurs in the lessaer curvature of the GI
tract.
 Doudenal Ulcer – occurs in the doudenum
 Esophageal Ulcers – occurs in the esophagus
Peptic Ulcer Disease
Cause of PUD
 Peptic Ulcer – some causes are unknown.
 Gastric Ulcers – significant numbers are caused by
Helicobacter Pylori (H. Pylori).
Risk Factors in the Development of PUD:
 Drugs ( NSAIDS, Corticosteroids)
 Alcohol
 Cigarette Smoking
 Acute medical Crisis or trauma (Stress)
Symptoms Common to all types of Ulcers
 Belching
 Bloating
 Epigastric pain radiating to the back (not associated
with the type of food eaten) and relieved by antacid
Nursing Assessment:
 Determine how food intake affects pain.
 Take Hx of antacid or histamine antagonist use.
 Determine presence of melena (blood in the stool).
 Determine presence and location of peptic ulcer.
Diagnostic Test
 Barium Swallow
 Upper endoscopy
 Gastric Analysis -indicating increased levels of
stomach acid.
Potential Complications
 Hemorrhage
 Perforation ( which always require surgery)
 Obstruction
NANDA Nursing Diagnosis
 Pain related to …
 Imbalance Nutrition: Less than body requirements
 Deficient knowledge deficit
 Risk for injury
NURSING PLANS and INTERVENTIONS
 Determine symptom onset and how symptoms are
relieved.
 Monitor color, quantity, consistency of stools and
emesis. Test for occult blood.
Nursing Plans and Interventions cont:
 Administer medications as prescribed.
- Antacids (Maalox): Need to take several times a day.
Administer after meals
Assess Hx of renal disease for Mg
products. Electrolyte adjustment can
result in renal insufficiency and
calcinosis.
- H2 receptor Antagonist – Cigarette smoking can
interferes with drug action.
Expensive.
Nursing Interventions
PUD Medications:
 Mucosal healing agent (Sucralfate) – to be taken at
leats 1 hour prior to meals.
Antacids interfere with absorption.
 PPI s - Taken before meals
Do not crush or chew
IV Pantoprazole to be given over 3 min period.
Inhibit absorption of other drug
Resume oral therapy as soon as feasible.
 Antiemetics
 Cough suppressants
 Stool Softeners
Nursing Management cont”
 Administer mucosal healing agent as prescribed.
 Encourage small , frequent meals, no bedtime snack
and avoid beverages containing caffeine.
 Prepare for surgery for uncontrolled bleeding,
obstruction, or perforation occurs.
- Gastric resection
- Vagotomy
- Pyloroplasty
 Teach client that DUMPING SYNDROME may occur
postoperatively.
Dumping Syndrome
 Secondary to rapid entry of hypertonic food into
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jejunum (pull water out of bloodstream)
Occurs 5-30 min after eating.
Characterized by vertigo, syncope, sweating, pallor,
tachycardia.
Minimized by small frequent meals, high protein, high
fat, low carb diet.
Exacerbate by consuming liquids with meals. Helped
by lying down after eating.
PUD Nursing Management cont.
 Teach client to avoid medications that increase risk for
developing peptic ulcer.
- Salicylates
- NSAIDS e.g. Ibuprofen
- Corticosteroid in high dosage
- Reserpine (antihypertensive)
- Anticoagulants
 Teach client lifestyle modification:
- Cessation of smoking and stress management.
 Teach client of symptoms of GI bleeding.
- Dark tarry stools
- coffee ground emesis
- bright red rectal bleeding
- Fatigue
- Pallor
- Severe abdominal pain ( report immediately) could denote
perforation.
Gastroenteritis
 Definition - Gastroenteritis is a condition that causes
irritation and inflammation of the stomach and intestines
(the gastrointestinal tract). Diarrhea, crampy abdominal
pain, nausea, and vomiting are the most common
symptoms.
 Causes:
- Viral infection
- Bacterial infection (Salmonella)
- Parasites
- Food-borne illness (such as shellfish) can be the
offending agent.
Causes of Gastroenteritis
 Viruses and bacteria are very contagious and can spread
through contaminated food or water. Gastroenteritis
caused by viruses may last one to two days. Bacterial cases
can last for a longer period of time.
Virus e.g. Norovirus, Rotavirus
Bacteria e.g Staphylococci, E. Coli, Shigella, Salmonella,
Campylobacter. Clostridium Difficile.
Parasite – Giardia (Giardiasis)
 Improper handwashing following a bowel movement or
handling a diaper can spread the disease from person to
person.
 Gastroenteritis that is not contagious to others can be
caused by chemical toxins, most often found in seafood,
food allergies, heavy metals, antibiotics, and other
medications.
Sign and Symptoms
Common symptoms may include:
 Low grade fever to 100°F (37.7°C)
 Nausea with or without vomiting
 Mild-to-moderate diarrhea
 Crampy painful abdominal bloating
More serious symptoms:
 Blood in vomit or stool
 Vomiting more than 48 hours
 Fever higher than 101°F (40°C)
 Swollen abdomen or abdominal pain
 Dehydration - weakness, lightheadedness, decreased urination,
dry skin, dry mouth and lack of sweat and tears are characteristic
findings.
 Signs and symptoms of both include pain, cramping, belching,
nausea, and vomiting. Severe cases may include hematemesis.
Diarrhea may occur with gastroenteritis.
Exams and Diagnostic Tests
 Blood and stool tests to determine the cause of the vomiting and
diarrhea.
 Physical examination.
 Complete Blood Count
 Ask if other family or friends have similar exposure or symptoms.
Ask about the duration, frequency, and description of the
patient's bowel movements and whether they are vomiting.
 Travel history: Travel may suggest E. coli bacterial infection or a
parasite infection from something that client ate or drank.
 Exposure to poisons or other irritants: Swimming in
contaminated water or drinking from suspicious fresh water such
as mountain streams or wells may indicate infection from
Giardia - an organism found in water that causes diarrhea.
 Diet change, food preparation habits, and storage.
Tests for Gastroenteritis
 In general, symptoms caused by bacteria or their
toxins will become apparent after the following
amount of time:
Staphylococcus aureus in 2-6 hours
Clostridium 8-10 hours
Salmonella in 12-72 hours
 Medications: If the patient has used broad-spectrum
or multiple antibiotics recently, they may have
antibiotic-associated irritation of the gastrointestinal
tract.
Other conditions associated with
Gastroenteritis
 Physical examination will provide reasons for
symptoms that may not be related to infection. If there
are specific tender areas in the abdomen appendicitis,
gallbladder disease, pancreatitis, diverticulitis, or other
conditions that may be the cause of the patient's
symptoms.
 Other noninfectious gastrointestinal diseases like
Crohn's disease or ulcerative colitis must also be
considered.
Treatment
 If the client cannot take fluids by mouth because of
vomiting, may insert an IV to put fluid back into the
body (rehydration).
 In infants, depending upon the level of dehydration,
intravenous fluids may be delayed to consider trying
oral rehydration therapy. Frequent feedings, as small
as a 1/6 ounce (5cc) at a time, may be used to restore
hydration.
Treatments for Gastroenteritis
 Antibiotics are not usually prescribed until bacteria have
been identified.
 Antibiotics may be given for certain bacteria, specifically
Campylobacter, Shigella, and Vibrio cholerae, if properly
identified through laboratory testing. Otherwise, using any
antibiotic or the wrong antibiotic can worsen some
infections or make them last longer.
 Infections, like salmonella, are not treated with antibiotics.
Supportive care of fluids and rest, the body is able to
resolve the infection without antibiotics.
 For adults, medications to stop vomiting (antiemetics)
such as promethazine (Phenergan, Anergan),
prochlorperazine (Compazine), or Ondansetron (Zofran).
These medications are prescribed as a suppository.
Treatments for Gastroenteritis
 Usually antiemetics are not recommend for
infants. Children who are a little older may be offered
antiemetic medication.
 Avoid antidiarrheal medications for all age groups
if they suspect the infection is caused by a toxin.
 Most common antidiarrheal agents for people older
than three years are over-the-counter medications
such as diphenoxylate atropine (Lomotil, Lofene,
Lonox) or loperamide hydrochloride (Imodium).
Nursing Care
 Acute gastritis is the irritation and inflammation of
the stomach's mucous lining. Gastritis may be caused
by a chemical, thermal, or bacterial insult. For
example, drugs such as alcohol, aspirin, and
chemotherapeutic agents may cause an attack of
gastritis. Likewise, hot, spicy, rough, or contaminated
foods may bring about an attack. Management
involves symptomatic treatment measures after
removal of the causative agent.
Nursing Management of Gastroenteritis
 Stop all P.O. intakes until symptoms subside.
 Assess the client's symptoms and administer the
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prescribed symptomatic relief medications such as
antacids and antiemetics.
Monitor intake and output closely. Excessive vomiting
or diarrhea may result in severe electrolyte depletion
that will require replacement therapy.
Administer and monitor IV therapy when ordered to
replace lost fluids.
Weigh daily to monitor weight loss.
Encourage the prescribed diet to maintain nutrition.
Constipation and Diarrhea
 Constipation – bowel movements that are infrequent, hard or
dry, and difficult to pass.
 Diarrhea – increased number of loose liquid stools.
 Causes of Constipation:
- Frequent use of Laxatives
- Advance age
- Inadequate fluid intake
- Inadequate fiber intake
- Immobilization due to injury
- A sedentary lifestyle
 Causes of Diarrhea:
- Viral Gastroenteritis
- Overuse of laxatives/laxative abuse
- Use of certain antibiotics
- Inflammatory bowel disease (Cronh’s disease – subacute,
chronic inflammation extending throughout the entire
intestinal mucosa (Terminal Ileum).
Diagnostic Procedures
 Fecal Occult Blood Test ( OB) – fecal sample is obtained
using a medical aseptic technique and wearing disposable
gloves. e.g. Hemoccult slide test and record result.
Certain food like red meat, raw vegetable and medication
(aspirin, NSAIDS) can cause false positive. Bleeding can be
a sign of CANCER (others include anal fissures,
hemorrhoids, inflammatory bowel disease, malignant
tumor, peptic ulcer) which can be contributing factor to
constipation.
An early sign of COLON cancer is rectal bleeding. Encourage
client 50 years of age and older and those with increased
risk factor to be screen with FOBT yearly and Routine
Colonoscopy at 50.
Clinical Manifestation of GI Bleeding
 Pallor: conjunctiva, mucous membranes, nail beds,
Dark tarry stools ( Peptic Ulcer due to mixture
of gastric acid and the blood) Macroscopic
Bright –red (constipation, bleeding from
anal fissure or sigmoid area).
Abdominal mass or bruit
Decreased BP, rapid pulse, cool ext. (s/s of
shock)
 Stress can cause or exacerbate ULCERS. Teach client
on stress-reduction methods and encourage those
with family of ULCERS to obtain medical survillance
for ulcer formation.
Diagnostic Procedures
 Digital Rectal Examination – Checks for
impaction. Client position on the left side with
knee flex. Client V/S and response should be
monitored.
 Stool Cultures – obtaining fecal samples using a
medical aseptic technique. Specimen should be
labeled promptly sent to the laboratory. Intestinal
bacteria can be a contributing factor for diarrhea.
Signs and Symptoms/Nursing Assessments
 Constipation:
- Abdominal bloating
- Abdominal cramping
- Straining at defecation
 Diarrhea:
- s/s of dehydration
- Frequent loose stools
- Abdominal cramping
Nursing Assessments:
 PE of the abdomen for BS and tenderness (auscultate before
palpation).
 S/S of fluid deficit
 Skin integrity around the anal area
 Collection of detailed history of the client’s diet, exercise, and
bowel habits.
NANDA Nursing Diagnosis (Constipation and Diarrhea)
 Constipation
 Diarrhea
 Fluid Volume Deficit
 Impaired skin integrity
Nursing Interventions (Constipation and
Diarrhea)
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Closely monitor client fluid status (D)
Monitor for client s/s of dehydration (D)
Closely monitor elimination pattern ( C) and (D)
Observe and document the character of BM ( C) and (D)
Carefully check for blood or pus. If the client is
experiencing diarrhea, measure the volume of the stool.
(D)
Administer laxatives or enemas as prescribed ( C)
Encourage adequate fluid intake ( C)
Monitor skin integrity ( D)
Suggest that client’s who are taking ATB to eat yogurt to
help re-establish an intestinal balance of beneficial
bacteria.
Complications
 Constipation:
- Fecal Impaction
- Development of hemorrhoids and/or rectal fissure
- Bradycardia, hypotension, and syncope associated
with the Valsalva Maneuver (bearing down)
stimulation of Vagus Nerve..
- Monitor constipation carefully and take measures
to treat and prevent constipation
- Removing fecal impaction. Break apart the impact
slowly. Monitor V/S and response. Preceded by
application of glycerin or Bisacodyl (Dulcolax supp.)
Complications
 Diarrhea:
- Dehydration. Monitor for s/s of fluid and electrolyte imbalance. Monitor for
metabolic acidosis cause by excessive loss of bicarbonate.
- Skin breakdown around the anal area. Carefully
follow skin protocol.
- Replace losses as prescribed.
Replacing Fluids and Electrolytes
 Drinking fluids is important during bouts of diarrhea to prevent dehydration,
which is the loss of vital fluids and electrolytes (sodium and potassium).
Proper hydration is especially important in children with diarrhea because they
can die from dehydration within a couple of days.
 Although water is extremely important in preventing dehydration, it does not
contain electrolytes.
 Good choices to help maintain electrolyte levels include broth or soups (which
contain sodium) and certain fruit juices, soft fruits, or vegetables (which
contain potassium).
 For children, often recommend a special rehydration solution that contains the
nutrients they need. You can buy this solution without a prescription.
 Examples of rehydration solutions include Pedialyte®, CeraLyte®, and Infalyte®.
Older Adults
 Older adults clients are more susceptible to developing
constipation as bowel tone decreases with age and
more at risk for developing fecal impaction.
 Adequate fluid and fiber intake and exercise are
important. Instruct proper diet.
Vegetables, fruits (especially dried fruits), and some cereals (whole
wheat, bran, or oatmeal) are excellent sources of fiber. It is easy to
remember that the harder a vegetable is (like celery), the more fiber it
has. To reap the benefits of fiber, it is very important to drink an
adequate amount of water to help with the passage of stool in the
intestines.
Crohn’s Disease Sign and Symptoms
 Abdominal pain
 Diarrhea and weight loss with patient becoming
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emaciated. Non- bloody diarrhea, crampy abdominal
pain. Weight loss is insidious.
Constant fluid loss.
Perforation of the intestine occurring due to severe
inflammation: constitute a medical emergency.
Fatigue
Low grade fever
Definitive Dx – shows intermittent granulomas, and
classic cobblestone appearance.
Other GI Conditions that manifest Constipation or
Diarrhea
 Ulcerative Colitis – Affects the superficial mucosa of
the colon, causing bowel to eventually narrow, shorten
and thicken due to muscular hypertrophy. Occurs in
the large bowel and rectum.
 Characteristic: Liquid stools containing blood, mucus,
and pus (10 to 20 stools per day).
Goal/Nursing Management Interventions
 Determine bowel elimination pattern and control
diarrhea with diet and medication.
 Provide nutritious well-balanced, low residue ,
low-fat, high-protein, high calorie diet; NO DAIRY
products.
Ulcerative Colitis -Goal/Nursing Management Interventions
 Administer Vit. Supplements and iron.
 Advise client to avoid food known to cause diarrhea such as
milk products and spicy foods.
 Advise client to avoid smoking caffeinated beverages,
pepper, and alcohol.
 Provide CBR with Intravenous hyperalimentation if
necessary ( TPN)
 Total Parenteral Nutrition (TPN)
Provides body with nutrition such as protein, sugar,
vitamins, minerals, and sometimes fat (lipids). TPN is used
when unable to eat or cannot get enough nutrition from
the foods you eat. TPN always goes into vein (blood vessel)
through an intravenous (IV) line. It may be given to you in
the hospital, long-term care center, or at home. May need
TPN for several days or longer.
Ulcerative Colitis -Goal/Nursing Management
Interventions
 Administer medication as prescribed.
Azulfidine(Sulfasalizine). Sulfasalazine is used to treat bowel
inflammation, diarrhea (stool frequency), rectal bleeding, and abdominal pain
in patients with ulcerative colitis
 Monitor I and O and serum electrolytes.
 Weigh at least 2x weekly.
 Provide emotional support.
 Encourage to talk with the enterostomal therapist
before surgery.
 If Ileostomy is performed, teach stoma care
Stoma Care
 The more distal the stoma is , the greater the chance for
continence.
 Ileostomy drains liquid material. Periostomal area is
prone to skin breakdown.
 Preoperative Care- Client and family must be informed
what to expect post operatively. Location, size, what it will
look like. Teach about how to care for stoma.
 Pouch Care
-The adhesive-backed opening is designed to cover the
stoma. Should be 1/8 clearance from the stoma.
- A rubber band or clip is use to secure the bottom.
- A simple squirt bottle is used to remove effluence from
sides of the bag. Pouch system is changed q 3-7 days.
- Client should maintain extra supply of pouches.
- Empty pouch is 1/3 to ½ full.
Stoma Care - Ileostomy
 Irrigation – Descending colon colostomies can be irrigated to
provide control over effulence.
- Irrigate same time daily.
- Use warm water (cold or hot can cause cramping)
- Wash around stoma with lukewarm water and a mild
soap.
- Commercial skin barriers may be purchased for home use.
 Odor Control – Commercial preparation are available.
Eliminate foods that can cause offensive odors.
 Diet – Ileostomy : high fiber foods can cause diarrhea and
maybe eliminated (popcorn, peanuts, unpeeled
vegetables.
Colostomy: Client should resume regular diet
gradually. Problem food preoperatively should be tried
cautiously.
Ileostomy /Colostomy
Special Colostomy or Colectomy Diet After Surgery
 Typically, a person will receive only IV fluids for 2-3 days
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after a colectomy or colostomy, to give the colon time to
heal.
After that, client can try clear liquids, such as soup broth
and juice, followed by easy-to-digest foods, such as toast
and oatmeal.
Client will be able to go back to your normal diet after this,
but should avoid certain foods that cause odors or gas,
which can over-inflate the colostomy bag and make it more
difficult to manage.
Foods that sometimes need to be limited, in order to make
it easier to manage your colostomy, include:
Raw vegetables
Skins and peels of fruit (fruit flesh is OK)
Special Colostomy or Colectomy Diet After Surgery
 Foods that sometimes need to be limited, in order to make
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it easier to manage your colostomy, include:
Dairy products
Very high fiber food such as wheat bran cereals and breads
Beans, peas, and lentils
Corn and popcorn
Brown and wild rice
Nuts and seeds
Cakes, pies, cookies, and other sweets
High fat and fried food such as fried chicken, sausage, and
other fatty meats
Special Colostomy or Colectomy Diet After Surgery
 Other foods can be helpful after a colostomy, to
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thicken the stool and minimize odors, include:
Yogurt (with live and active cultures)
Cranberry juice
Bananas
Applesauce
Well-cooked, sticky white rice
Buttermilk
Tapioca
White toast
Special Colostomy or Colectomy Diet After
Surgery
 Finally, instruct the client to thoroughly chew
everything she/he eat. Chewing is an important part of
the digestive process and we all chew our food to some
degree. However, if the client make a special effort to
chew food very well, it will help manage the colostomy
more easily. Instruct to try to chew everything until it
is liquid in your mouth.
Diverticular Diseases
 Diverticulosis and Diverticulitis
 Diverticulosis – bulging pouches in the GI wall which
push the mucosa lining through the surrounding
muscle.
 Diverticulitis – inflamed diverticula, which may cause
obstruction, infection and hemorrhage.
Diverticular Diseases
Nursing Assessment
 Left Lower Quadrant pain
 Increased flatus
 Rectal Bleeding
 S/s of Intestinal Obstruction – alternating
constipatuion and diarrhea, abdominal distention,
anorexia,& low grade fever.
Diverticulitis
 Diagnostic Procedure – Barium Enema or Colonospy.
 Perforation is confirmed by radiograph (Barium not
used during acute phase).
NANDA NURSIN DIAGNOSIS
 Ineffective tissue perfusion
 Pain
 Imbalance Nutrition: less than body requirements.
Nursing Plan and Interventions
 Provide a well-balanced diet, high fiber diet unless
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inflammation is present. Inflammation present –
NPO followed by LOW Residue, bland foods.
Include bulk forming laxatives such as Metamucil in daily
regimen.
Increase fluid intake to 3 L/day.
Monitor I and O and bowel elimination.
Avoid constipation.
Observed for Complications:
- Obstruction.
- Peritonitis
- Hemorrhage
- Infection
Other Conditions: Bowel Obstruction
 Non-Mechanical: Paralytic Ileus
 Mechanical : Bowel Obstruction within the Bowel
Tumors or Diverticulitis. Outside the bowel: Hernia and
adhesions.
Assessment:
-Sudden onset of abdominal pain.
- Hx of abdominal surgeries
- Distention
- Increase peristalsis when obstruction first occur then
peristalsis becomes absent when paralytic ileus occurs.
- Bowel sound are high-pitched
Nursing Plans and Interventions
 Maintain client NPO with IV fluids and electrolyte
therapy.
 Monitor I and O. FC maintains strict output.
 Implement Nasogastric Intubation. Ensure that
client has patent airway to prevent cyanosis.
Check for presence of deviated septum of the
nares.
Proper placement needs to be determined via X-Ray.
Canto, Miller-Abbot, or Harris tubes are passed
through the nose into the stomach usually by HCP.
Advance tube every 1-2 hours.
Nursing Plan and Interventions (NGT)
Do not secure to nose until reaches specified position.
Reposition q 2 hours to assist with placement of the tube
Connect to suction.
Irrigate with air only
Note amount, color, consistency and any unusual odor of
drainage.
Cont/Management of Bowel Obstruction
 Document pain. Medicate as prescribed.
 Assess abdomen regularly for distention, rigidity,
change is bowel sounds.
 If conservative treatment fails surgery is indicated.
Nursing Management
 Client admitted with c/o constipation, thready stools,
and rectal bleeding for few months is diagnosed with
rectal mass. Priority is:
-Place client on NPO
- NG Tube
- IV fluids
- Surgical preparation of bowels (if obstruction is
complete).
- Teaching ( preoperative, nutrition, etc.)
Colorectal Cancer
 Colorectal Cancer is 2nd most common cancer and the
second leading cause of death in Western countries
including U.S.
 They are adenocarcinomas (colon epithelium).
 Grows slowly. Client at many times can be
asymptomatic, but occult blood is discovered in
the stools during a rectal exam.
Colorectal Cancer
 CRC can metastasize (through blood or lymph) to the
liver (most common).
 Spread can also occur as a result of peritoneal seeding
(seeding can occur during surgical resection of
tumor).
 Can be cured with early detection.
 Regular colorectal screening is recommended for
individuals older than 50 years of age or with a family
history of colorectal cancer.
Risk factors for Colorectal Cancer
 Colon cancer is more common in women while rectal cancer is
more common in men.
 Risk Factors: Adenomatous colon polyps.
Family Hx of colorectal cancer.
Inflammatory Bowel Diseases
(Ulcerative colitis, Crohn’s Disease)
High Fat, Low Fiber diet.
Older than 50 year of age.
Hx of ovarian or breast cancer
Most Common Area is the rectosigmoidal region.
Diagnostic Procedures and Nsg. Intervention
 Fecal Occult Blood Test (FOBT)
- 2 stool samples within 3 consecutive days.
- Instruct the client to avoid ingestion of some food or
drugs because result can be false positive. In,
general, instruct to avoid meat, NSAID’s, and
Vitamin C are avoided for the 48 hour period prior
to testing.
Diagnostic Procedures and Nsg. Intervention
 Carcinoembryonic Antigen (CEA) serum test – CEA levels are
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elevated.
CEA is a type of protein molecule that can be found in many different
cells of the body, but is typically associated with certain tumors and the
developing fetus.
CEA is most frequently tested in blood. It can also be tested in body
fluids and in biopsy tissue.
The normal range for CEA in an adult non-smoker is <2.5 ng/ml and
for a smoker <5.0 ng/ml.
The best use of CEA is as a tumor marker, especially for cancers of the
gastrointestinal tract.
When the CEA level is abnormally high before surgery or other
treatment, it is expected to fall to normal following successful surgery
to remove all of the cancer.
A rising CEA level indicates progression or recurrence of the
cancer. In addition, levels >20 ng/ml before therapy are
associated with cancer which has already spread (metastatic
disease).
Diagnostic Procedures and Nsg. Intervention
 Sigmoidoscopy/Colonoscopy
- Provides definitive diagnosis of CRC. This scope
procedure permits visualization of tumors, removal of
polyps, and tissue biopsy.
- Bowel is cleansed prior to procedures with GoLYTELY
or other cathartics.
- Barium Enemas – CT scan of the abldomen, pelvis,
lung, and liver; chest X-Rays, and liver scan maybe
done to further identify the specific location of cancer
and to identify sites of metastases.
Colorectal cancer is the third most frequently diagnosed cancer in men and women and
the second highest cause of cancer deaths in the U.S. Yet, when found early, it is highly
curable. This type of cancer occurs when abnormal cells grow in the lining of the large
intestine (colon) or rectum.
Colorectal cancers often begin as polyps – benign growths on the surface of the
colon. The two most common types of intestinal polyps are adenomas and
hyperplastic polyps.
Colorectal Cancer Screening
Because colorectal cancer is stealthy, screenings are the key to early detection. Beginning at age 50,
most people should have a colonoscopy every 10 years. This procedure uses a tiny camera to
examine the entire colon and rectum. These tests not only find tumors early, but can actually
prevent colorectal cancer by removing polyps (shown here).
Virtual Colonoscopy
There is now an alternative to colonoscopy that uses CT scan images to construct a 3-D model of
your colon. Called virtual colonoscopy, the procedure can reveal polyps or other abnormalities
without actually inserting a camera inside your body. The main disadvantage is that if polyps are
found, a real colonoscopy will still be needed to remove and evaluate them.
X-Rays of the Colon (Lower GI)
X-Rays of the colon -- using a chalky liquid known as barium as a contrast agent -- allow your doctor
a glimpse at the interior of the colon and rectum, offering another way to detect polyps, tumors,
and changes in the intestinal tissue. Shown here is an "apple core" tumor constricting the colon.
Like the virtual colonoscopy, any abnormalities that appear on the X-rays will need to be followed
up with a conventional colonoscopy.
Staging Colorectal Cancer
If cancer is detected, it will be "staged," a process of finding out how far the cancer has spread. Tumor size may
not correlate with the stage of cancer. Staging also enables your doctor to determine what type of treatment you
will receive.
Stage I – Cancer has not spread beyond the inside of the colon or rectum
Stage II – Cancer has spread into the muscle layer of the colon or rectum
Stage III - Cancer has spread to one or more lymph nodes in the area
Stage IV – Cancer has spread to other parts of the body, such as the liver, lung, or bones. This stage does NOT
depend on how deep the tumor has penetrated or if the disease has spread to the lymph nodes near the tumor.
Colorectal Cancer Surgery
In all but the last stage of colorectal cancer, the usual treatment is surgery to remove the tumor and
surrounding tissue. In the case of larger tumors, it may be necessary to take out an entire section of
the colon and/or rectum. The good news is that surgery has a very high cure rate in the early stages.
If the cancer has spread to the liver, lungs, or other organs, surgery is not likely to offer a cure -- but
removing the additional tumors, when possible, may reduce symptoms.
Treating Advanced Colorectal Cancer
When colorectal cancer has spread to one or more lymph nodes (stage III), it can still be cured.
Treatment typically involves a combination of surgery, radiation (being administered here), and
chemotherapy. If the cancer comes back after initial treatment or spreads to other organs, it
becomes much more difficult to cure. But radiation and chemotherapy can still relieve symptoms
and help patients live longer
Radiofrequency Ablation
Radiofrequency ablation (RFA) uses intense heat to burn away tumors. Guided by a CT scan, a
doctor inserts a needle-like device that delivers heat directly to a tumor and the surrounding area.
This offers an alternative for destroying tumors that cannot be surgically removed. In patients with
a limited number of liver metastases that cannot be removed by surgery, chemotherapy is
sometimes combined with RFA for tumor destruction.
Preventing Colorectal Cancer: Diet
There are steps you can take to dramatically reduce your odds of developing colorectal cancer.
Researchers estimate that eating a nutritious diet, getting enough exercise, and controlling body fat
could prevent 45% of colorectal cancers. The National Cancer Institute recommends a low-fat diet
that includes plenty of fiber and at least five servings of fruits and vegetables per day.
Therapeutic Procedures and Nsg. Interventions
 Colon resection, colectomy, colostomy, and abdominoperineal
(AP) resection surgeries maybe performed to removed all or
portions of CRC. Post surgery complication – monitor for s/s of
Dumping Syndrome.
 Preoperatively the client is on CLEAR LIQUIDs for a couple of
days prior to surgery, bowel prep with cathartics
(GoLYTELY) is performed, and antibiotocs such as neomycin
and metronidazole (FLAGYL), are administered to eradicate
intestinal flora (prevent infection).
 Chemotherapy – monitor for myelosuppression and
pantocytopenia. (decreased WBC production leads to
decreased ability to fight infection, RBC – anemia characterized
by fatigue, SOB and platelets (easy bleeding)
 Radiation – monitor for fatigue and diarrhea.
Above are all posiible adjuvant therapies.
Colorectal Assessment
 Monitor for s/s of:
- fatigue due to occult blood loss.
- Change in bowel habits ( constipation or diarrhea)
- Visible blood in the stool.
- Mass of digital rectal examination.
- S/s due to metastases – partial bowel obstruction
(high pitched tingling bowel sound), complete bowel
obstruction ( no BS in 5 minutes).
Postoperatively:
 If there is stoma:
- assess the color and integrity of the stoma.
(stoma should be reddish pink, moist, and may have
small amount of visible blood immediately
postoperative):
- report any evidence of stoma ischemia or necrosis e.g
dark or cyanosis color.
Nursing Interventions
 Instruct client with strong hx of colorectal cancer to
reduce intake of fats and meat proteins.
 Explain the need for, and side effects of,
chemotherapy, surgery, and radiation therapy.
 Closely monitor intake and output and the client’s
elimination pattern.
 Closely observe for visible or occult signs of bleeding.
Post –operative Care
 Maintain NGT suction (decompression).
 Parovide pain management, generally with PCA.
 Monitor output from drain(s).
 Provide wound care.
 Provides measure to reduce risk for respiratory
complications (turn, cough, deep breath, ambulate,
splint).
 Promotes measures to reduce risk for embolic
complications (compression stockings, low level
anticoagulation).
Post- Operative Care
 Slowly progress diet, monitoring client response.
 Provide client education regarding activity limits (no
lifting, use of stool softeners to avoid straining).
 Provide ostomy teaching (signs of ischemia to report,
expected output, appliance management), if
applicable.
 Support the client with disturbed body image.
Complications and Nursing Implications
 Bowel Obstruction
- monitor for high-pitched BS before site of obstruction with
hypoactive BS after, or overall hypoactive bowel sounds.
- decompression and/or surgical intervention.
 Perforation (erosion of the wall of the intestine) resulting to
lower GI bleeding and peritonitis.
- Monitor hemoglobin, hematocrit, and stools for evidence
of bleeding.
- replace losses ( fluid replacement or blood transfusion).
- Support the client during and following surgical intervention.
- Administer antibiotics as prescribed.
 Abscess or Fistula
- Prepare the client for incisional/surgical drainage.
- provide antibiotic as prescribed.
Implication to Older Adults:
 Older adults have more difficult postoperative course
and are at a greater risk for intraoperative
complications.
 Older adult clients may be less able to handle fluid
volume deficits.
 Management of colostomy maybe more difficult with
older adult clients due to impaired vision and the need
for fine motor skills.
Hemorrhoids
 Hemorrhoids
- Enlarged veins located in the lower part of the rectum
and the anus.
- They become swollen because of increased pressure
within them, usually due to straining at stools and
during pregnancy because of the pressure of the
enlarged uterus.
Classification
 Internal
 External
Hemorrhoids
Internal Hemorrhoids
 Located in the inside lining of the rectum.
 Cannot be felt.
 Usually painless and make their presence known by
causing bleeding with a bowel movement.
 Internal hemorrhoids can prolapsed or protrude
through the anus.
External Hemorrhoids
 Located underneath the skin that surrounds the anus
 Can be felt when they swell and may cause itching or
pain with a bowel movement, as well as bleeding.
 A thrombosed external hemorrhoid occurs when
blood within the vein clots, and can cause significant
pain.
Hemorrhoids Diagnostic Test
 Diagnosis of hemorrhoids is usually made by history
and physical examination.
 Inspection of the anus and a digital rectal examination
are often performed.
 Sometimes anoscopy may be required where a small,
lighted scope is introduced into the anus to examine
the inner lining of the anus and rectum.
 If there is the potential that the bleeding source
originated above the rectum from other parts of the
colon, sigmoidoscopy or colonoscopy by a
gastroenterologist may be recommended.
Diagnostic Procedures
 If there is concern that significant bleeding has
occurred, a CBC (complete blood count) to measure
hemoglobin and hematocrit levels is obtained.
 If the patient is on warfarin (Coumadin), a
prothrombin time (PT) or INR may be done to
measure the blood clotting levels.
Sign and Symptoms
 Painless bleeding -may be bright red blood on the
outside of the stools, on the toilet paper, or dripping
into the toilet. The bleeding usually is self-limiting.
Bleeding with a bowel movement is never normal
and should prompt a visit to a health care
practitioner.
NANDA Nursing Diagnosis
 Pain
 Knowledge Deficit
 Anxiety
Hemorrhoid Treatment
 Warm Sitz Baths
- Sitting in a few inches of warm water three times a
day for 15-20 minutes may help decrease the
inflammation of the hemorrhoids.
- It is important to dry off the anal area completely after
each Sitz bath to minimize irritation of the skin
surrounding the anus.
 Dietary Changes
- Increased fluid intake and dietary fiber (roughage)
will decrease the potential for constipation
Hemorrhoids Treatments
 Stool Softeners
- Stool softeners may help but once hemorrhoids are
present, liquid stools may cause inflammation and
infection of the anus.
 Activity Suggestions
-Teach client with hemorrhoids should not sit for long
periods of time.
- May benefit from sitting on an air or rubber donut.
Exercise is helpful in relieving constipation and in
decreasing pressure on the hemorrhoidal veins.
Individuals should be encouraged to have a bowel
movement as soon as possible after the urge arises.
Hemorrhoids Treatment
Surgery
 Rubber band ligation
 Sclerotherapy: Sclerotherapy describes a procedure when a
chemical is injected into the hemorrhoid causing it to scar.
 Laser therapy: Laser therapy can be used to scar and harden internal
hemorrhoids.
 Hemorrhoidectomy: Hemorrhoidectomy is a surgical procedure done
in the operating room. Most aggressive approach and there is a
markedly decreased chance of the hemorrhoids returning.
 Stapled hemorrhoidectomy: Stapled hemorrhoidectomy is the
newest surgical technique for treating hemorrhoids, and it has rapidly
become the treatment of choice for third-degree hemorrhoids.
Prevention
 Prevention
 The risk of hemorrhoids can be decreased by eating a
high fiber diet, staying well hydrated, getting
regular exercise, and trying to have a bowel
movement as soon as possible after the urge
arises.
Practice Questions
Question # 1
In preparing for colonoscopy procedure, which task is
most suitable for the nurse to delegate to the UAP?
a. Explain the need for clear liquids 1-3 days prior to
procedure.
b. Reinforce NPO status 8 hours prior to procedure.
c. Administer laxatives 1-3 days prior to procedure.
d. Administer and enema the night before the
procedure.
Question # 2
 The nurse is preparing for a client with peptic ulcer
disease. Which assessment finding requires
immediate intervention?
a. Projectile vomiting.
b. Burning sensation 2 hours after eating.
c. Coffee-ground emesis.
d. Board-like abdomen with should pain?
Question # 3
 In educating a client with GERD, the nurse will teach
the client that the drug therapy is a “step up” approach
that depends on the response to the medication. For
the drug listed, which is the anticipated order that the
HCP will try in the treatment plan?
a. Magnisium Trisilicate (Gaviscon) and Famotidine
(Pepcid AC)
b. Ranitidine (Zantac)
c. Pantoprazole (Protonix)
__________, __________, ___________
Question # 4
 You are preparing to give an enteral feeding through a
NGT. Place steps in correct order:
a. Assess for bowel sounds.
b. Auscultate tube for placement and check pH.
c. Flush the tube with water.
d. Reflush the tube with water.
e. Administer the feeding.
f. Check for residual volume.
____,______,______._____,_____,_____
Question # 5
 The nurse is assigning care for the am shift. Which of
these clients is most appropriate to assign to the
LPN/LVN?
a. A client with oral cancer who is scheduled in the
morning for glossectomy.
b. An obese client returned from surgery following
vertical banded gastroplasty.
c. A client with anorexia nervosa with muscle
weakness and decreased urine output.
d. A client with intractable nausea and vomiting
related to chemotherapy.
Question # 6
 The nurse is teaching the client and family how to do a
colostomy irrigation. Place the information in correct order.
a. Hang the container at about shoulder height.
b. Allow the solution to flow slowly and steadily for
5-10 minutes.
c. Put 500 to 1000 ml of lukewarm water in the
container.
d. Allow 30 -45 minutes for evacuation.
e. Lubricate the stoma cone and gently insert the
tubing tip into the stoma.
f.
Cleanse, rinse, and dry skin, and apply a new drainage
pouch.
g. Put on a pair of clean gloves.
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Question # 7
 In planning a treatment and prevention program of
chronic fecal incontinence for an elderly client, which
intervention should the nurse try first?
a. Administer glycerin suppository 15 minutes
before evacuation time.
b. Insert a rectal tube at specified intervals each day.
c. Assist the client to the bedpan or toilet 30
minutes after meals.
d. Use incontinence brief pads or adult-sized
diapers.
Question # 8
 A client with cirrhosis is at risk for developing
complications. Which condition if noted by the nurse
requires immediate intervention?
a. Black, tarry stools and decreased urination from
unusually low blood pressure.
b. Shortness of breath and increasing abdominal girth
and size.
c. Edematous lower extremities.
d. Sudden relaxation of muscles of the hand and hold
a sustained posture.
Question # 9
 For clients coming to the ambulatory care GI clinic,
the nurse would be most appropriate if will assign
which task to the LPN/LVN?
a. Teach the client self-care measures for
hemorrhoids.
b. Assist the HCP in incision and drainage of a
pilonidal cyst.
c. Evaluate the client’s response to sitz bath for an
anorectal abscess.
d. Describe the basic pathophysiology of an anal
fistula to a client.
Question # 10
 A client underwent an exploratory laparotomy 2 days
ago. Which physical assessment finding should the
nurse immediately report to the HCP?
a.
b.
c.
d.
Abdominal distension and rigidity.
NG tube intentionally displaced by client.
Absent or hypoactive bowel sounds.
Nausea and occasional vomiting.
Question # 11
 The nurse is assigning rooms for several clients. Which two
client would be best suited to put in the same room?
a. A 35 –year old female with copious, intractable
diarrhea and vomiting.
b. A 43-year old female second day post-op with
cholecystectomy.
c. A 53-year old female with pain related to alcoholassociated pancreatitis.
d. A 62-year old female with colon cancer receiving
chemotherapy and radiation.
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