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6/2/19

Intestinal & Rectal Disorders Chapter 24

Tammy W Brown MSN, RN University of Mobile

Adult Health II

Constipation

• Infrequent/irregular stools • Abnormal hardening of stools • Decrease in volume of stool • Retention of stool for a prolonged time

What are some of the causes of Constipation? • Medications • Physical conditions • Endocrine disorders • Surgery • Psychological • Poor dietary habits • Age • Lifestyle

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Manfestations

• < 3 bowel movements/week • Abdominal pain / distention • Anorexia • Straining with BM • Small, hard, dry stool • Hemorrhoids • Anal fissures • Hypoactive bowel sounds

What do I do to help my patients poop? • Increased fiber / fluid • Laxatives ONLY if recommended or prescribed

(p. 715) • Discontinue meds causing problem IF possible • Do not ignore the urge to defecate • Relieve anxiety • Bowel training

– Improve consistency of stool – Establish a regular time for elimination – Stimulate emptying on a routine basis

Complications• Impactions – Care with digital removal – Vasovagal response

• Bradycardia, hypotension, syncope • Hemorrhoids (internal or external)

– Bleeding /Itching / burning – Sitz baths, analgesic ointments / creams, good hygiene

• Anal fissures • Megacolon

– Abdominal distention, leakage of liquid feces, constipation – May lead to intestinal perforation

• Straining (Valsalva Maneuver) – Initially briefly lowers blood pressure – **Secondary reaction is a rapid increase in BP above normal** – If patient strains too long, may ultimately lead to vasovagal response

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Diarrhea

• Increased frequency of BMs (>3 per day)

• Increased amount of stool • Liquid / watery stool

• Acute – < 2 weeks – Usually infectious

• Chronic – > 4weeks – Physiological conditions

Risks

• Medications • Enteral feedings • Physiologic disorders • Infections • Food intolerances / allergies • Traveler’s Diarrhea

Manifestations • Frequent, watery stools • Abdominal distention / bloating • Cramps • Intestinal “rumbling” • Hyperactive bowel sounds • Excessive thirst • Anorexia • Incontinence

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What can I do to make it stop? • Treat the underlying process – History (medication, dietary, conditions) – Exposures / travel

• Control the symptoms – Hydration (oral / IV) – Low fiber / bulking diet – Avoid caffeine, carbonated beverages, hot/cold foods – Avoid milk, high fat foods, fresh fruits / veggies – Lomotil or Imodium to reduce number of stools

Prevent Complications • Dehydration – Assess for s/s FVD

• Electrolyte imbalances – Hypokalemia – **May cause Dig toxicity for those on

digoxin (Lanoxin)** • Skin breakdown – Perianal excoriation

Fecal Incontinence

• What is it? • What causes it? • Why is it commonly seen in the elderly? • What nursing care is required for patients

who are incontinent of stool?

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Irritable Bowel

Syndrome (IBS)

Most common GI disorder

25-40 million people are affected (mostly women / teens – early 40’s)

• colon becomes hypersensitive • overreacts to mild stimulation • Instead of slow, rhythmic muscle movements,

the bowel muscles spasm • Leads to diarrhea and/or constipationSeems to be associated with heredity, high fat diet, alcohol, smoking, extreme stress, irritating foods (caffeine, spices, greasy, etc.)

Manifestations

• Diarrhea • Constipation • Mixed (alternating diarrhea / constipation) • Pain brought on by eating and improved with

defecation • abdominal distention

Treatment & Management 1. Relieve pain 2. Control symptoms

• Learn triggers (what foods, activities, etc.)

• High fiber diet / increased fluids • Antidepressants/ antispasmodics

/ probiotics / antibiotics / antidiarrheals / prevent constipation

• Smoking / alcohol cessation • Small, frequent meals

3. Reduce stress • Exercise • Relaxation techniques

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Malabsorption • Inability to absorb major vitamins, minerals, and nutrients • Causes: – Celiac Sprue (sensitivity to gluten (wheat, barley, rye);

triggers an immune response in small intestines) – Zollinger-Ellison Syndrome (pancreatic / duodenal ulcers

cause a hypersecretion of acid that leads to multiple ulcers)

– Gastric / Intestinal surgeries (gastrectomy, bariatric – GBP) – Lactose intolerance (inability to digest lactose) – Inhibited bacterial growth in the bowel (antibiotics)

Manifestations • Loose, bulky stools / diarrhea • Gray color / may be yellow • Fatty / oily stool (steatorrhea) • Foul-smelling stool • Abdominal distention / pain • Fatigue / malaise (iron, B12) • Weight loss (fat, carbohydrates) • Malnutrition

• Easily bruise (vitamin K) • Osteoporosis (Ca+ / vitamin D) • Vison problems esp. at night (vitamin A)

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Management • Supplementation of vitamins, minerals, nutrients • Management of primary disease states – Celiac: eliminate dietary gluten – Lactose: avoid dairy products / Lactose free – C-Diff: Flagyl (metronidazole) – Zollinger-Ellison: PPIs

• Anti-diarrheals • Oral / IV fluids • Monitor / treat complications

Appendix

• 4 inch long appendage / attached to the cecum

• Actual purpose unknown

• Thought to harbor “good bacteria” that helps to keep the intestines healthy

• Prone to obstruction and infection

Appendicitis • Inflammation of the

appendix (kink or occlusion) leading to increased pressure within the appendage

• Most common reason for emergency abdominal surgery

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Manifestations • Vague/ dull pain in the periumbilical area

that progresses to the RLQ as a sharp pain • Low grade fever (99°-102°) • Nausea with / without vomiting • Loss of appetite • “Rebound” tenderness (pain with release) • Constipation or diarrhea may be present

UMBILICUS

ANTERIOR-SUPERIOR ILIAC SPINE

MCBURNEY’S POINT PALPATION ON THE LEFT LOWER QUAD CAUSES PAIN IN THE RIGHT LOWER

QUAD

Diagnosis

• Physical exam • Symptoms • Laborotory tests – CBC (elevated WBCs)

• Diagnostic imaging – Abdominal x-ray / US – CT scan

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Treatment • Surgery is usually immediate (within

hours) – Usually laparoscopic – May be open in the case of perforation

with infection • Prophylactic antibiotics • IV fluids • NPO

Pre-Op Nursing Management • Signed consent (after pt speaks with

surgeon) • Patent IV • NPO • Administer antibiotics • IV fluids • Gown • Chlorhexidine wash of lower abdomen /

pelvic area • Pain medications / positioning / ice

Post-Op Management • IV fluids until tolerating PO

– Food will usually be given the day of surgery with BS

• Pain medications – May radiate to shoulder – IV (acute) / PO (home)

• Assess surgical sites – 3 puncture sites (lap) with 2x2 / tegaderm

covering; closed with glue / steri-strips or sutures

– Small 2-4 inch vertical incision RLQ (open) closed with glue/steri-strips, sutures, or staples / covered with gauze dressing and surgical tape

• Discharge day of surgery or next (lap) • Discharge usually 48-72 hours after surgery (open)

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Perforation of Appendix • Rupture of the appendix – Peritonitis

• Infection throughout the abdominal cavity

– Abscess • Pocket of pus that forms in

the abdominal cavity

• Abdominal cavity lavage • JP drain 5-7 days post-op – Drainage will be increased

secondary to wash-out – Clear to “pus” colored

• NG tube until BS return

Pain may be relieved initially with the perforation, but wide-spread intense pain will quickly return

Remember A-P-P-E-N-D-I-X

Abdominal pain

Point of McBurney’s will have the most pain

Poor appetite

Elevated temperature

Nausea with or without vomiting

Desire to be in the fetal position to relieve pain

Increased WBC, inability to pass gas or have a bowel movement

eXperiences rebound tenderness

Diverticular Disease

• Diverticulosis – A weakening of

intestinal muscle wall leads to a herniation of the mucosa

– Sac-like pouch is formed that collects bowel contents • Inflammation and

infection (diverticulitis)

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Manifestations

• Diverticulosis – Vague GI symptoms

• Diverticulitis – Acute onset of pain – Constant, mild-severe, most often LLQ – Fever, increased WBC’s (leukocytosis) – N/V

Colonoscopy • Clear liquids the day before • Laxative prep starts the afternoon / night before

– Mix it with something flavored, like a sports drink or powdered drink mix

– Keep it well chilled – Drink it through a straw placed far back on your tongue – Follow it with a sip of something good tasting – Suck on a lemon slice or piece of hard candy after drinking

• Results in – Frequent, forceful diarrhea – Bloating, cramping – N/V

• Patent IV • After

– Vital signs – Monitor for severe acute pain, , n/v, fever/chills, abdominal

distention (perforation)

Treatment for Diverticulitis • Diet – Clear liquid until symptoms are gone, then high-fiber,

low-fat • Antibiotics 7-10 days – Cipro & Flagyl

• OTC pain reliever (acetaminophen) – Avoid NSAIDs

• Antispasmodics (Bentyl or Levsin) – Anticholinergic effects

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Acute Cases Not Controlled as Outpatient

• IV fluids / NPO • NG tube to suction (if vomiting not

controlled) • IV antibiotics • Dilaudid for pain (IV) – Contraindications for Morphine

inconclusive

Surgical Treatment

• Abscess – CT guided percutaneous drainage • imaging guidance is used to place a needle or catheter

through the skin into the abscess to remove or drain the infected fluid; offers faster recovery than open surgical drainage

• Resection (colectomy) with anastomosis – Area of diverticulitis is removed and the two

remaining ends are re-joined

• Colectomy with double-barreled colostomy – Usually reversed (re-anastamosis) at a later time

• Complications of surgery – DVT, pneumonia, infection, hemorrhage

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Complications of Diverticulitis • Peritonitis • Abscess – Pain, mildly hardened mass that can be palpated,

fever, leukocytosis • Perforation – Sudden, intense pain – Rigid abdomen – Absent BS – s/s of shock may be present

Peritonitis (“Hot Abdomen”)

• Inflammation of the lining of the abdominal cavity and of the lining of the organs contained within (peritoneum)

Manifestations • Acute abdomen (early)

– Generalized pain aggravated by movement – N/V, low grade fever – Diminished BS

• Late stages – Constant, localized at site of infection /

increased in severity – Rigid abdomen / distention – Rebound tenderness – Tachypnea, tachycardia, hypotension,

dyspnea – Leukocytosis

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Treatment • IV fluid bolus (NS)

– Treat hypovolemia • Pain meds / Antiemetics • NG tube for decompression • Respiratory assistance may be necessary

– O2 / mechanical ventilation / Bi-pap / CPAP • High-dose broad spectrum IV antibiotics • Surgery to treat the cause (appendix, abscess,

perforation, etc.) • Intensive monitoring

Nursing Management • Vital signs • Assess GI function, F&E balance • Pain relief

– Positioning / meds • CL diet with return of flatus / BS • Monitor drains • Monitor for complications

– DVT / PE – Sepsis – Abscess formation post-op – Dehiscence post-op

• Wound separation – Evisceration post-op

• Abdominal organs protrude through incision

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• Inflammatory bowel disease that leads to chronic inflammation with development of scattered ulcerations on the mucosa

• Can affect any part of the GI tract • Symptoms

– Come on gradually (insidious) – Pain (commonly RLQ) unrelieved by defecation – Fatigue – Diarrhea (steatorrhea) / Intense cramping, especially after

eating – Weight loss / malnutrition / anemia – Electrolyte imbalances

Crohn’s Disease

• Complications – Perforation – Anal fissures

• Tear (pain/ burning with defecation and bleeding) – Anal fistulas

• Tunnel that develops between the skin and the anus (pain, drainage of pus-like fluids, swelling, bleeding)

• Extra-Intestinal Symptoms – Arthritis – Tender, red skin nodules – Eye disorders (conjunctivitis) – Oral ulcers

Ulcerative Colitis (UC) • chronic disease of the colon, in which the lining of the

colon becomes inflamed and develops ulcerations that are continuous in nature (no healthy tissue between)

• Symptoms – Bloody, mucous diarrhea / + guaiac – Abdominal pain (LLQ) – Urgency / a constant feeling of the need to defecate

(tenesmus) – Fever / fatigue – Anorexia / weight loss / malnutrition – N/V, dehydration

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• Complications – Hypovolemic shock – Perforation – Kidney stones – Colon cancer – Hemorrhage – Toxic megacolon

• Chronic distention of the colon (abdominal pain, distention, tachycardia, fever, diarrhea)

• If not responsive to treatment (IV corticosteroids, IV fluids, antibiotics, NG to suction) within 72 hours, surgery (total colectomy) is NECESSARY!

• Daily – Increase oral fluids – Low residue / high protein / high calorie – Vitamin supplements – Avoid smoking, caffeine, alcohol, excessive dairy – Prescribed NSAID’s with reduced likelihood of bleeding

(Asacol, Pentasa) – Methotrexate / Imuran/ Remicade (immunosupressants)

Treatment of

Inflammatory Bowel Disease

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• NPO / IV fluids (oral fluids if at home / limit solid foods) • Systemic corticosteroids (oral if at home) • IV antibiotics (oral if at home)

– ciprofloxacin (Cipro) & metronidazole (Flagyl) • TPN for long-term inability to tolerate PO • Antidiarrheals / bulking agents • Pain medications

– Tylenol (acetaminophen) – Opioids (in acute-care setting)

• surgery – UC (may cure) – Crohn’s (symptoms will usually recur)

Treatments during Flare-Ups

ILEOSTOMY / COLOSTOMY • What is it? • What is the drainage like? • Does an ileostomy always need a bag? • What should the stoma look like? • What type of education do these patients

need? • What are some complications?

Colo-Rectal Disorders • Polyps

– Usually no symptoms (bleeding may occur) – Usually benign, but monitored closely – Removal during colonoscopy

• Cancer – Third most common site for cancer – Second most common cause of death in men ages 40-79 – Early diagnosis with prompt treatment is the best cure (goes

from 13% 5-year survival to 90% 5-year survival) – Asymptomatic in most cases until in late stages

• Preventative screening is a must • Begin at age 50

– If no family history or no findings, repeat every 10 years

– Family history or findings, repeat every 5 years or sooner

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Manifestations • Early stages are usually asymptomatic • Symptoms appear gradually, may go unnoticed until late stages • Early

– Fatigue – Minor changes in bowel habits with minimal bleeding

• Late – Abdominal pain – Tenesmus – Rectal bleeding (#2) / extreme change in bowel habits (#1) – Unexplained weight loss / anemia

Treatment

• Dependent upon stage – Tumor removal

• Curative or palliative

– Radiation • Before surgery to shrink tumor • After to to reduce recurrence rate / kill any remaining cells • Provides symptom relief if tumor is inoperable

– Chemotherapy

Nursing Managmement

• Reduce risk of post-op complications • Education – Medications – Lifestyle changes (with colostomy) – Psychological implications

• Assist with palliative care options – Hospice

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Intestinal Obstructions • A blockage prevents the normal flow of digestive contents

through the intestines • Small bowel (Most common)

– Intussusception (telescoping) – Twisting of the bowel (volvulus) – Tumors / hernias – Adhesions (scarring)

• Large bowel – Tumors – Diverticulitis – Inflammatory bowel disease

Manifestations

Small Bowel • Acute symptoms • Colicky, wavelike, cramping pain • Blood / mucous may pass • No stool • Vomiting of stomach contents, then

bile, then fecal vomiting • Abdominal distention • Diminished bowl sounds (dependent

upon location)

Large Bowel • Symptoms appear and progress

slowly • Constipation • Melena • Stools may become smaller in size as

obstruction increases in size • Abdominal distention • Weight loss / anorexia • Crampy, lower abdominal pain • Fecal vomiting

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Treatment

SBO • NG tube for decompression • NPO / IV fluids • Surgery to correct the cause • What would your nursing care

include?

LBO • Colonoscopy for decompression

and correction • Surgery to correct the cause • Rectal tube for decompression • What would your nursing care

include?

Pilonidal Cyst

• Usually located at lower sacral area • Thought to be the result of a hair(s)

that grows into the subQ tissue (“in- grown hair”

• May be congenital secondary to abnormal epithelial skin growth

• May be asymptomatic until inflammation / infection occurs

• Redness / swelling / drainage at site

Treatment (surgery is necessary

if abscess forms)

Oral or IV antibiotics

Incision & Drainage • Can be done in clinic or at

bedside if inpatient • Local anesthetic • Incision is made to drain the cyst • Wound is left open and packed

with gauze dressing to allow it heal by secondary intention

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Education

Showers (no tub baths)

Pain medication about an hour before dressing change

If dressing is “stuck”, moisten it (works well after shower) before removing

Use donut for sitting

Keep area free from hair

UN IVE

RS ITY

MO BIL

PR OD

UC TIO