NU 350 Lower GI
What are the characteristic s/s of irritable bowel syndrome (IBS)?
Intermittent and recurrent abd pain associated with alteration in bowel function
Altered bowel motility: Diarrhea or constipation, sometimes both
Urge to defecate
Sensation of incomplete evacuation
Social anxiety due to diarrhea
Embarrassment from defecating before reaching bathroom
What are the risk factors and precipitating factors for IBS?
Affects 10-15% of the Western population bc of bad diet
Affects 2-3 times more women than men
Major factors precipitating IBS:
How is IBS diagnosed?
History from patient:
- Symptom history
- Past medical history
- Psychosocial history
- Family history
- Drug & dietary history- NSAIDS, digitalis, vasopressin, estrogen, & allopurinol
Diagnostic testing to rule out other illness with similar symptoms: colorectal cancer, PUD, inflammatory bowel disease, & mal-absorption disorders
Rome III Criteria for diagnosis of IBS:
- 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
- Relieved with defecation
- Onset associated with change in stool frequency and/or appearance
What is the treatment for IBS?
Encourage pt to verbalize concerns
Diet: At least 20-35 grams of fiber/day
May include psyllium (metamucil)
Avoid gas-producing foods (broccoli, cabbage, onion)
Substitute yogurt for milk products if lactose intolerant
Relaxation & stress management
Acupuncture & Chinese herbs
What are the medicines used for drug therapy of IBS? How do each sooth IBS symptoms? What is therapy that is effective for all pts with IBS?
Anti-spasmotic agents (Bentyl): prevents diarrhea, may be helpful if taken before meals to alleviate pain
Loperamide (Imodium): a synthetic opioid, enhances intestinal water absorption and sphincter tone
Lotronex: Used to treat diarrhea & severe pain in women who have failed other therapies. Monitored closely because of side effects (severe colitis)
No single therapy has been found effective for all patients.
What is appendicitis characterized by? When is it common?
Inflammation of appendix caused by kinking, edema, or blockage of the appendix. Blockage could be from popcorn kernals, nails, fecal matter, seeds, etc.
Generalized pain, localized to RLQ
Common in late adolescence and early adulthood; decreases after age 25; becoming more common in elderly d/t baby boomers (incr. pop).
What are the s/s of appendicitis?
Generalized pain localized to RLQ
Tenderness or pain at McBurney's point btwn the umbilicus and the iliac crest
Low grade fever
Temporary constipation and failure to expel flatus
Rovsing's sign (pain on palpation of LLQ)
What are the complications of appendicitis?
Inflamed appendix fills with pus and may rupture causing peritonitis, can cause sepsis. If it ruptures, the pain dissipates.
Paralytic ileus (lack of bowel sounds) can occur (sometimes occurs after surgery)—A/B and wound drain, keep in Semi-Fowler’s.
How is appendicitis diagnosed?
High WBC (10-16) w/ shift to left or more than 75% neutrophils
How is appendicitis treated?
Surgery: Lap or Traditional
- Keep HOB up
- Check Bowel Sounds (NPO until BS return)
- Morphine for pain
- C&DB (cough and deep breath)
What are the characteristics of inflammatory bowel disease? How is it classified?
Chronic, recurrent inflammation of the intestinal tract
Clinical manifestations are varied
Remission with periods of exacerbations
No known cause. Possible include infectious agent, autoimmune reaction, food allergies, heredity (both classifications occur more families)
IBD is classified based on symptoms:
- Ulcerative colitis (UC)
-Crohn’s disease (Can be caused by drinking too much carbonated soda) occurs most often in the ileum of the intestine
Both can be debilitating
What are the clinical differences btwn UC and Crohn's?
Age of onset: -teens-mid 30s -teens-mid 30s
Diarrhea: -common -common
Abd cramp: -common -common
Abd pain: -common -common
Fever: -acute attacks -common
W t loss: -rare - severe
Rectal bleed: -common -infrequent
Tenesmus: -common -rare
Malabsorption: -minimal -common
nutritional defic .
*Tenesmus is feeling that you constantly need to pass stools, even though your bowels are empty. May involve straining, pain, and cramping.
**UC can occur later in men (50s)
***Crohn's pts have more of a problem w/ weight loss bc of frequent diarrhea
What are the pathological differences between UC and Crohn's?
- UC - continuous starts in rectum, spreads to colon. Most common in lg. intestine
- Crohn's - skipped lesions occur anywhere in GI from mouth to anus, common in ileus of the sm. intestine.
- UC - Continous areas of inflammation
- Crohn's - Healthy tissue btwn inflammation
- UC - mucosa and submucosa thickness
- Crohn's - Entire bowel wall
Granulomas (localized nodular inflammation):
- UC - Occasional
- Crohn's - Rare
- UC - rare
- Crohn's - very common
Pseudopolyps (projecting masses of scar tissue, develop from granulation tissue during repeated cycles of ulceration):
- UC - common
- Crohn's - rare
Small bowel involvement:
- UC - minimal
- Crohn's - common
What are the characteristics of ulcers in Crohn's?
Ulceration of the intestinal mucosa leads to thickened bowel and fissures can develop. Deeper ulcers than with U.C. More likely to have fistulas
What are the different complications associated with UC and Crohn's?
UC: Strictures (occasionally), perforation, toxic mega colon, carcinoma increased after 10 years, no recurrence after colectomy
Crohn's: Fistulas, Strictures, anal abscesses, perforation, carcinoma increased in sm. intestine, recurrence after surgery is common at anastomosis site.
How is IBD diagnosed? What diagnostic tests should a nurse anticipate ordered? What would be abnormal in those tests in a pt w/ IBD?
Rule out other diseases w/ similar symptoms, then determine if pt has UC or Crohn's
CBC: typically shows iron deficiency in anemia from blood loss, WBC may be elevated w/ toxic mega colon or perforation
Electrolytes: Decreases in Na, K, Cl, bicarb, and Mg levels d/t losses from diarrhea and vomiting
Albumin: With severe disease, poor nutrition, protein loss
Sed Rate: Elevated d/t chronic inflammation
Stool cultures for blood, pus, mucus
Sigmoidoscopy - Since UC begins in rectum, rectal biopsy may be adequate for dx. Not as thorough as colonoscopy
Colonoscopy - More likely for Crohn's as it is usually in sm. intestine, but can be anywhere
What assessment data should a nurse gather and anticipate for a client w/ IBD?
- Past medical history-infection, autoimmune disorders
- Family history
- Medications-use of antidiarrheal meds
- Functional health patterns-N/V/D, anorexia, weight loss, blood or mucus in stools, lower abdominal pain that is worse before defecation
- Intermittent fever
- Emaciated appearance
- Pale skin with poor turgor, dry mucous membranes, anorectal irritation, abd distention, hyperactive bowel sounds, abd cramps, tachycardia, hypotension
What are the goals of treatment for the IBD pt?
Rest the bowel
Provide symptomatic relief using drug therapy
What is the goal of drug therapy in the IBD pt? What classes of meds are used?
The goal of drug therapy is to induce and maintain remission to improve quality of life
5 classes of meds are used:
- Biologic and targeted therapy (started when initial therapies are not effective)
What are the characteristics of aminosalicylate therapy for IBD? How do they work? What should a nurse teach about them?
Sulfasalazine and Asacol (DMARD):
First line tx for UC and Crohn’s
Tx of mild to moderately severe attacks
Anti-inflammatory specific to mucous membranes in intestines (doesn't work until it reaches the intestines)
Maintenance of clinical remission
After remission obtained, therapy is cont’d w/gradual reduction over several months
Maintenance dose continued for at least 1 year
May cause yellowish orange discoloration of skin and urine
Teach patient to avoid sunlight due to photosensitivity
Do not take other salicylates (Aspirin)
What are the drugs and parameters for antimicrobial use for IBD?
Used even though no infectious agent has been identified
What corticosteroids are used in tx of IBD? Why? What teaching should a nurse implement?
P rednisolone and budesonide ( Entocort )
Corticosteroids are used to achieve remission but not effective in maintaining it
Oral for mild to moderate dz,
IV steroids for severe dz
Rectal foams & cortisone directly applied
Given shortest possible time d/t side effects associated with long term use
What immunouppresants are used to treat IBD? What are their characteristics?
Imuran and Purinethol: Given to maintain remission after corticosteroid tx
Methotrexate (more for Crohn’s): watch for flu like symptoms, bone marrow depression, and liver dysfunction (need to check CBC, liver enzymes). Causes birth defects
Anti-tumor Necrosis Factors (Remicade, Humira) (Crohn’s)
Why are sedatives used for IBD?
Reduce anxiety and restlessness
What anti-diarrhea agents are used in IBD?
Imodium and Lomotil
What percent of those with UC and Crohn's require surgery? When is surgical therapy indicated?
UC: 25-40%, cured with colectomy
Crohn's: 75%, but can return in sm. intestine
- Pt fails to respond to tx
- Exacerbations are frequent & debilitating
- Massive bleeding, perforation, strictures, or obstructions
- Carcinoma develops
What surgical procedures are used for IBD?
Total proctocolectomy with permanent ileostomy
- removal of the colon, rectum, and anus with closure of the anus
- the end of the ileum is brought out to form a stoma in the RLQ
Total proctocolectomy with continent ileostomy
- formation of a Kock pouch which is drained by a catheter
Total colectomy with ileo-anal reservoir
- Combo of 2 sx, 8-12 weeks apart
- 1 sx- colectomy, ileoanal anastomosis, reservoir construction, and temporary ileostomy
- 2 sx- closing ileostomy to direct stool to new reservoir
What post-op care is indicated for IBD surgeries?
Pain assessment. Frequently comes from gas and abd distention
If ileostomy is formed, monitor:
- Stoma viability
- Mucocutaneous juncture
- Peristomal skin integrity
- Ileostomy output (initially 1500-2000ml/24 hours)
Observe for signs of hemorrhage, abdominal abscess, small bowel obstruction, and dehydration
What are the goals and principles of nutrition therapy for the IBD pt?
Adequate nutrition without exacerbating symptoms
Correct & prevent malnutrition
Replace fluid & electrolyte losses
Prevent weight loss
Balanced, healthy diet with sufficient calories, protein, and nutrients; individualized
Initially NPO (bowel rest)
High-calorie, high-protein, low-residue diet
Avoid foods that cause/exacerbate symptoms:
- Cold foods
- High fat foods
- Dairy products (lactose intolerant)
- High -residue foods (whole-wheat bread, cereal w /bran, nuts, raw fruit )
- Smoking increases GI motility ( avoid)
Enteral supplements & parenteral nutrition may be needed
Supplemental iron may be necessary
May need vitamin therapy (B-12 injections)
What nursing interventions should a nurse implement for the IBD pt?
Assess pt, check labs, etc
Accurate I & O
What are the characteristics of polyps in the large intestine?
Arise from mucosal surface of colon & project into the lumen
Common in rectosigmoid area
Most are asymptomatic
Occasional rectal bleeding
Places the pt at high risk for developing cancer
What are the characteristics of Familiar Adenomatous Polyposis (FAP)?
Genetic disorder characterized by hundreds to thousands of polyps that eventually become cancerous, usually by age 40
50% of offspring will carry the gene
Anyone with family hx should have genetic testing in childhood
If the gene is present, colorectal screening begins at puberty and colonoscopy at age 16
Tx is prophylactic removal of colon, by age 25
These people are also at risk for other cancers, so they should have lifetime cancer surveillance
What diagnostic studies are used for pts w/ polyps?
Colonoscopy: regular or pill
All polyps are considered abnormal & should be removed
Surgery not indicated unless carcinoma or certain cases of polyposis are present
What are the nursing management principles for scopes?
Observation after procedure:
-Slight abdominal pain, cramping and gas is normal after procedure
-Watch for symptoms that indicate hemorrhage or perforation:
- Severe abdominal pain
- Abdominal distention
What are the characteristics of colorectal cancer (CRC)?
Second leading cause of cancer-related deaths in U.S.
Symptoms do not appear until disease is advanced
Vital: Regular screening to detect precancerous lesions
85% of cases arise from adenomatous polyps
What are the risk factors of CRC?
More common in men than women
Most occur in the latter end of the colon
Mortality rates higher among AA
- Increasing age
- Family or personal hx or CRC
- Colorectal polyps
- Large intake of processed or red meat
What are the clinical manifestations of CRC?
Nonspecific and do not appear until advanced
- Alternating constipation and diarrhea
- Change in stool caliber (narrow, ribbon-like)
- Sensation of incomplete evacuation
- Vague abdominal discomfort or cramping
- Colicky abdominal pain
- Occult bleeding
What are the guidelines of screening for CRC?
Begin at age 50 to 75 years old
FOBT (fecal occult blood test)
- 3 consecutive stool samples
Sigmoidoscopy (misses 50%)
- Every 5 years
Colonoscopy (gold standard for dx)
- Average risk-should be done every 10 years
- AA should & high risk should start at 45
What is the only treatment for CRC? What are the goals of this treatment?
Surgery is the only cure
- Complete resection of the tumor
- Exploration of abdomen to determine metastasis
- Removal of lymph nodes that drain the area where CA is located
- Restore bowel function
- Prevent surgical complications: peritonitis and perforation
Reduction of colonic bacteria is done prior to sx (GoLYTELY)
The site of CRC determines the site of the resection
What are the principles of chemo and radiation therapy for CRC?
Used an adjunct therapy following colon resection
Used for palliative care for non-resectable CRC to reduce tumor size
Can be used prior to surgery to reduce tumor for easier removal
Chemo recommended when patient has + lymph nodes
FYI: Current chemo protocol (Triple protocol)
- Folfox (5-FU plus leucovorin and oxaliplatin)
- Folfiri (5-FU plus leucovorin and irinotecan)
Some people cannot handle the triple therapy. Capecitabine is used as an acceptable tx.
Don't need to know specific drugs.
What is an ostomy? A stoma?
An ostomy is a surgical procedure that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen.
A stoma is an opening on the surface of the abdomen, created when the intestine is brought through the abdominal wall & sutured to the skin. Fecal matter empties via stoma rather rectum. May be permanent or temporary
What does a nurse need to know about post-op care of a stoma? What do the different colors mean?
Assess color, size, suture line.
- Mild to moderate: Normal in initial post-op period & first 2-3 weeks. Can be due to trauma
- Moderate to severe: Obstruction, allergic reaction to food, gastroenteritis
Bleeding: small amount normal after surgery or when touched, otherwise should be evaluated
Report any separation, report nausea and abd distention STAT.
During first 24-48 hours, mucosal drainage then passage of flatus is normal.
Post op: Ambualte to get the gut moving!
Normal: shiny and moist, dark pink to red. Should look like the inside of your mouth.
Light pink (pale) - anemia
Dark red-blue (dusty) color - decreased circulation (ischemia)
Blue-gray to black color - strangulated bowel, surgical emergency
Why are ostomies used?
Used when normal elimination is no longer possible
- Person has CRC, the diseased portioned must be removed along with a certain margin of healthy tissue
- Sometimes the tumor and tissue can be removed leaving enough healthy tissue to anastomose (reconnect) the remaining ends of the healthy bowel.
- Other times there is too much taken to reconnect therefore the need for an ostomy
Ostomies are described according to their location and type
What are the different types of ostomies? How does the location of the ostomy affect output from the stoma?
Ileostomy: Ostomy in the ileum. Output from ileostomy has not entered colon, therefore, it is liquid to toothpaste consistency, drains continually and a pouch must be worn. More at risk for dehydration.
Colostomy (sigmoid or transverse): Ostomy in the colon. May be temporary or permanent. Sigmoid ostomy output resembles normal formed stool and patients can regulate these and not have to wear a bag at all.
Cecostomy: Ostomy in the cecum, usually temporary
The more distal the ostomy is the more the intestinal content resemble feces eliminated by intact colon and rectum.
What are the characteristics of a single barrel or end stoma?
End stoma (single barrel):
- Surgically created: proximal end of bowel used to create a single stoma
- Distal portion removed (permanent) or sewn together and left in the abdominal cavity (Hartmann’s pouch - procedure done to close the end of the sigmoid-rectal area w/ a colostomy formation, permanent).
- Leaving the distal pouch in leaves the potential for the bowel to be anastomosed again
- Bowel is brought through abd wall, foled onto itself like a turtleneck collar and sutured to skin
- Proximal end of bowel ends in stoma, distal portion of bowel sutured and inactive.
- No connection btwn proximal and distal portion of bowel.
What are the characteristics of a loop stoma?
Loop of bowel brought to the surface & anterior wall opened to provide fecal diversion
A plastic rod is used to hold it in place for 7-10 days
Surgeon brings out an intact bowel loop through the abdominal wall and then makes an incision on the top of the loop.
All of these require use of ostomy appliances to collect fecal matter.
What are the characteristics of a double-barrel stoma?
Bowel is divided & both ends brought through abdominal wall as separate stomas
Proximal – functioning stoma, output is stool
Distal – mucous fistula, output is mucus
Usually temporary diversion
What are the stool characteristics of the colostomy compared to the ileostomy?
- ascending – semi-liquid
- transverse – semiliquid to semiformed
- sigmoid – formed
Ileostomy: liquid to semiliquid
What two preventative treatments are musts when caring for ostomies? Which type of ostomy does not need these and can have irrigation and bowel training?
A stool pouch and skin barriers are a must w/ ileostomy and most colostomies.
Generally, only w/ sigmoid colostomies bowel training and irrigation can be performed, pouch and barriers may not be needed.
What are the principles of pre-op care and post-op care of the ostomy patient?
- Psychologic preparation-change in body image
- Colostomy teaching
- Bowel preparation- Mag Citrate & GoLytely
- IV & oral antibiotics to decrease intracolonic bacteria
- Assessment of the stoma
- Protecting the skin
- Selecting pouch
- Helping patient adapt – physically & psychologically
What are a nurse's responsibilities regarding maintenance and patient teaching in colostomy care?
Explain what colostomy is for and how it functions
Describe underlying need that resulted in need for ostomy
Have patient demonstrate and practice the following activities
Remove old skin barrier, cleanse skin and apply new skin barrier
Apply, empty, clean and remove the pouch
Empty the pouch before it is 1/3 full to prevent leakage
Irrigate the colostomy to regulate bowel elimination (optional)
Explain how to obtain colostomy supplies
Talk about potential strain on sexual activity
Irrigation stimulates emptying of the colon. When the colon is irrigated and emptied on a regular basis, no stool is eliminated between irrigation sessions. This allows the patient to wear only a pad or small pouch over the stoma.
If the stoma bag gets too full and leaks, it will never be sealed again. You must clean it up and change the bag. Gastric contents will cause skin breakdown.
What should a nurse know about nutritional therapy in ostomy management? What foods should ostomy patient avoid? What foods could cause diarrhea and obstruction of the ostomy?
Promote fluid intake of at least 3000 ml/day
- Increase during hot weather, excessive perspiration, and diarrhea
Teach s/s of electrolyte imbalances
Call HCP if fever, diarrhea, skin irritation, stoma problems
Dietary modification: well-balanced diet
- odor-producing foods - eggs, garlic, onions, fish, asparagus, cabbage, broccoli, alcohol
- gas forming foods - broccoli, beans, carbonated beverages, beans, cabbage, cauliflower, brussel sprouts, asparagus
Stoma output varies: modify diet based as needed
- Diarrhea: Cabbage, beer, spinach, green beans, coffee, raw fruits, spicy foods
- Obstruction: Nuts, raisins, popcorn, dried fruits, seeds, raw veg, celery, corn, meats with casings. Chew these VERY thoroughly
What does a nurse need to know and teach about ileostomy care?
Drainage is frequent; may be damaging to the skin
Pouch worn at all times & emptied when 1/3 full
If leakage occurs, the pouch must be removed, changed, and the skin cleaned & dried promptly
Low - fiber diet ordered initially & fiber re-introduced gradually
Avoid popcorn, coconut, mushrooms, olives, stringy vegetables, food with skins, dried fruits and meats with casings (obstruction)
Susceptible to obstruction because the lumen is less than an inch in diameter
What should a nurse anticipate regarding normal and harmful behaviors during a patient's adaptation and acceptance of an ostomy?
Grief period is common
Concerns : Body image, sexuality, change in lifestyle
Psychological support-experience fear and anxiety
May become angry, depressed or resentful
Might not want to look at the ostomy. Have them look at it w/ a mirror if they don't want to directly see it.
Pt. must not be forced too quickly into care of stoma until ready
ADL’s are generally resumed in 6-8 weeks
Resuming sports varies from HCP to HCP
Refer patients for counseling if needed
What are some complications of an ostomy?
Prolapse - The bowel protrudes out of the stoma
Retraction of stoma in bowel - surgical emergency
Necrosis of the stoma - surgical emergency
Peristomal hernia - protrusion of abdominal contents through the abdominal wall defect created during ostomy formation, most common complication
Peristomal skin breakdown or infection - usually from stool at the site or fungal infection.
- Will have red rash, pustules, pruritis at the site, possibly candida if fungal.
- Use nystatin powder to treat topical candidiasis
What are some other principles of ostomy care a nurse should know?
Change if ANY leakage: DON’T be a LAZY nurse--it will be detrimental to the patient’s skin
Ileostomies: More liquid and acidic drainage erodes wafer. Average 3-7days for wafer changes
Keep pouch emptied to prevent pulling away from the skin which leads to spilling of contents which leads to breakdown and infection
How would a nurse change the stoma bag?
1. Measure the opening size for stoma
2. Apply ostomy powder and skin prep. This takes off the oil in order for ostomy to stick
3. Apply paste to ostomy wafer
4. Place ostomy wafer, can apply water-resistant tape around wafer if needed
5. Paste to ostomy wafer before applying bag, don't get paste on the stoma
6. Place the bag, it snaps onto the ring
What is a two piece ostomy pouch? What teaching should a nurse include for the patient?
There is a separate wafer and pouch.
It allows the pouch to be removed, rinsed out, and new pouch to be put on daily.
- End of pouch should be rolled over the clamp only ONE time.
- Keep supplies away from the sun or extreme temperatures
- Precut supplies before flying
- Pre-sized wafers available once stoma size determined
What teaching about meds should a nurse give to an ileostomy pt?
Liquid and tablet meds only, preferably liquid.
Extended release tablets will not be absorbed properly. (Most colostomy pts do not have this problem)
What should a nurse know before irrigating a stoma?
Never force into opening. If unable to insert tube into stoma, call MD as stoma stenosis (narrowing) may be developing.
Stop for a while if cramping occurs, then resume more slowly
What complications should a pt w/ an ostomy report?
Change in configuration, color, consistency of stool
Bleeding through stoma or rectum
Persistent leakage around wafer, diarrhea, or lack of stool
Change in contour or color of stoma (should be brick red like inside of mouth)
What are diverticula? What is the difference between diverticulitis and diverticulosis?
Diverticula: saccular dilations or outpouchings of mucosa through circular smooth muscle of the intestinal wall. Pockets in the intestinal tract. things get in them. Frequently found in the sigmoid colon.
Diverticul osis –multiple, non-inflamed.Often free of symptoms or slight abdominal discomfort
Diverticul itis –inflammation of diverticula
What is the etiology of diverticulitis?
Common GI disorder
Affects 5% of population by age 40
50% of the population by age 80
Affects men & women equally, but men tend to have more complications
Most are asymptomatic
No known cause
Appears to be associated with a deficiency in dietary fiber
What is the patho of diverticulosis? Diverticulitis?
- When diverticula form, smooth muscle of the colon wall becomes thickened
- Lack of dietary fiber slows transit time & more water is absorbed from the stool, making it difficult to pass through the lumen
- Decreased bulk of stool & more narrowed lumen in the sigmoid colon cause high intraluminal pressures
- These factors are believed to contribute to the formation of diverticula
- Cause of diverticulitis is r/t retention of stool in the diverticulum, forming a hardened mass called a fecalith
- Inflammation & usually small perforations form
- Inflammation spreads to the surrounding area in the intestines, causing tissue edema
- Abscesses may form, or complete perforation with peritonitis may occur
What are the clinical manifestations and complications of diverticulitis?
Majority of pts have no symptoms
Crampy abdominal pain
Alternating constipation & diarrhea
Approximately 15% of pts. with diverticulosis progress to acute diverticulitis
Abdominal pain over area involved
Tender LLQ mass w/palpation
Fever, increased WBC, chills, nausea, anorexia may be present
Elderly patients may have normal WBC, be afebrile & have little, if any pain
Complications include perforation, peritonitis, abscess & fistula formation, bowel obstruction, & bleeding
Bleeding manifested by maroon stools & usually resolves spontaneously
What diagnostic tests are utilized in diverticulitis?
Based on history and physical
Abdominal and chest x-rays rule out other causes of abdominal pain
CT scan with oral contrast is preferred diagnostic tool
Some other test that will be done could include:
- Barium enema
- Fecal sample
- Barium enema & colonoscopy not done if pt. has acute diverticulitis due to risk of perforation/peritonitis
How should a nurse teach a patient to prevent diverticular disease?
High-fiber diet, mainly fruits and veggies
Decreased intake of fat and red meat
High levels of physical activity decrease risk
Weight loss if obese
Bulk laxatives (Metamucil)
Increased fluid intake
What is the treatment and goal of treatment for acute diverticulitis?
Some patients can be managed at home with PO antibiotics, while others have to be hospitalized if pain is severe
Pain management (Morphine)
Approx 30% acute diverticulitis will require surgical intervention (resection and/or temp colostomy)
The goal of treatment is to let the colon rest and the inflammation subside
What are the principles of surgical intervention for diverticulitis?
Reserved for patients with complications, such as abscesses or obstructions
Involves resection an obstructing inflammatory mass
May require resection of the involved colon with a temporary diverting colostomy
The colostomy is re-anastamosed after the colon has healed
What should a nurse include in in interventions for a pt w/ acute diverticulitis?
Increased fluid intake
S/S of perforation/peritonitis (severe abdominal pain)
How to decrease complications & avoid exacerbation
What are the characteristics of hemorrhoids?
Internal or External
Common in all age groups
Supporting tissue in the anal canal weakens, usually from straining & venules become dilated
In addition, blood flow is impaired through the veins of the hemorrhoidal plexus
An intravascular clot in the venule results in a thrombosed external hemorrhoid
Most common cause of bleeding w/defecation
Over time may cause iron-deficiency anemia
- rectal bleeding
What are some causes for hemorrhoids?
Straining to defecate
Prolonged standing & sitting
What methods are used for diagnosis of hemorrhoids? How is it treated?
- Digital Rectal Exam, anoscopy, or sigmoidoscopy
- Visual inspection
Therapy directed toward cause & symptoms:
- High-fiber diet
- Increase fluid intake
- Ointments w/anti-inflammatory agents & analgesics for topical use: dibucaine (Nupercainal), Hydrocortisone, Witch hazel
- Stool softeners
- Sitz baths
- Ice/warm packs for thrombosed external hemorrhoids
- Internal hemorrhoids may require surgical intervention
What are the treatments for external and internal hemorroids? When is surgery indicated?
External hem. conservative treatment
Internal hem. nonsurgical approach
- Band ligation – through anoscope, ligated with rubber band
- Infrared coagulation – using infrared or electrical currents
- Cryotherapy – rapid freezing of hemorrhoid
- Laser treatment – used less often
- used in prolapse or marked protrusion
- severe pain
- severe bleeding
- large hemorrhoids
- multiple thrombosed
What are important concepts for a nurse to know in post-op hemorrhoid management?
OTC med use
Sitz baths (15-20 min 2-3 Xs a day X 1 week)
- Started 1-2 days after sx
- Provides comfort
- Keeps anal area clean
Packing may be inserted in rectum, removed day 1 or 2
Sphincter spasm pain managed by opiods
- painful to defecate
- Some people avoid going to bathroom due to dreaded pain
- docusate (Colace)
- If no BM in 2-3 days, oil-retention enema is given
Teach s/s of complications & when to call doctor: excessive pain, bleeding or fever
Be sensitive in talking to the pt about hemorrhoids or surgical site, some are embarrassed about it.
What is an anal fissure? What are the causes? How are they classified?
Skin ulcer or crack in the lining of the anal wall
- Local infection
Classified primary or secondary:
Primary – from local trauma associated with defecation
- High pressure in the internal anal sphincter can result in ischemia & result in fissuring
- Vaginal delivery
Secondary – due to a variety of conditions
- Inflammatory bowel disease (Crohn’s, UC)
- Prior anal surgery
- Infection: Syphillis, TB, Gonorrhea, Chlamydia, Herpes, or HIV
What are the clinical manifestations of an anal fissure? How is it diagnosed?
- Severe during and after defecation
- Described as “passing broken glass”
- Bright red
Constipation may result from a fear of pain with defecation
Diagnosed through physical examination
What are the treatments for anal fissures?
Adequate fluid intake
- Anesthetic suppositories (Anusol-HC)
Bowel regulation – mineral oil/stool softeners
Most acute fissures take 2-4 weeks to heal
What is an anal fistula? What are the usual problems that accompany the disease?
Abnormal tunnel leading out from the anus or rectum
May extend to the outside of the skin, vagina, or buttocks
Complication of Crohn’s disease & may progress to anal abscess
Feces may enter the fistula & cause infection
May have persistent blood-stained purulent discharge or stool leakage from the fistula. Patient may need to wear a pad to prevent staining of clothes
What is the treatment for an anal fistula? How will you care for it post-treatment?
- the fistula is opened
- healthy tissue is allowed to granulate
- excision of the entire fistulous tract
- Gauze packing is inserted and the wound is allowed to heal through granulation
Care is the same as with a hemorrhoidectomy
What are the pathophysiology and complications of an intestinal obstruction?
6-8 L of fluid enter the small bowel daily
Most of the fluid is absorbed before it enters the colon
When there is an obstruction, fluid, gas and intestinal contents accumulate above the obstruction
Distal bowel collapses
B owel above the obstruction becomes distended as the intraluminal pressure rises
The increased pressure causes fluid and electrolytes to be leaked out of the blood vessels to the peritoneal cavity, which leads to severe reduction in circulating blood volume causing hypotension and hypovolemic shock.
If the blood flow in the intestines in inadequate, bowel tissue becomes ischemic, then necrotic and the bowel may perforate.
In some cases the bowel can become so distended that the blood flow is halted causing edema, cyanosis and gangrene of bowel--Called intestinal strangulation or intestinal infarction. Must be corrected quickly or will lead to rupture, massive infection, and death.
What causes intestinal obstruction? What are the different classifications and types of intestinal obstruction?
Occurs when intestinal contents cannot pass through the GI tract.
Occurs anywhere in the colon
Partial or complete
What are the most common causes of mechanical obstruction in the small intestine and in the large intestine?
- Surgical adhesions most common cause
- Hernias and tumors next leading cause
- Carcinoma most common cause
- Followed by volvulus (an obstruction with a loop of bowel that has twisted on itself) and diverticular disease
What characterizes a non-mechanical obstruction?
Occurs from a neuromuscular or vascular problem
Paralytic ileus most common form (lack of intestinal peristalsis and no bowel sounds)
Can occur after surgery
Inflammatory response (acute pancreatitis, appendicitis)
Thoracic or lumbar fractures
What are pseudo-obstructions and vascular obstructions?
- Apparent obstruction without demonstration by x-ray
- Is idiopathic (no obvious reason or cause)
- Result of interference of blood supply to a portion of the intestines
What are the clinical manifestations of an intestinal obstruction?
Depends on location
N/V, poorly localized abd. pain, abd. distention, inability to pass flatus, obstipation (obstruction of flow of feces) and s/s of hypovolemia: cold hands and feet, light headedness, infrequent urination, increased heart rate, weakness.
NO bowel sounds below obstruction.
High pitched bowel sounds above obstruction. (Borborygmi – audible bowel sounds)
- Distal obstruction can cause vomitus containing feces.
- Projectile containing bile-salts.
- Metabolic alkalosis with high obstruction N & V
- Vomiting relieves pain in upper obstructions
- Is more constant with lower obstructions (and will most likely experience abdominal distension).
- Wave like pain – classic in mechanical obstruction
- Paralytic ileus – more constant & generalized.
- Strangulation – severe constant pain.
What are the clinical s/s of intestinal obstruction in the small intestine compared to the large intestine?
Small: Rapid onset, frequent and copious vomiting, colicky,cramp-like, intermittent pain, feces for a while, increased abd distention.
Large: Gradual onset, vomiting is rare, low-grade cramping abd. pain, no bowel movement, increased abd distention.
What are the diagnostic studies used for intestinal obstruction?
CT scans and abdominal x-rays are most useful
Sigmoidoscopy and colonoscopy provide direct visualization
Elevated WBC indicates strangulation or perforation
Decreased H & H indicate bleeding
Electrolytes, BUN & creatinine are monitored for dehydration
What are the principles of care a nurse should anticipate regarding intestinal obstruction?
STAT surgery if bowel strangulated
Most resolve with conservative tx
Initial medical tx include:
- NG tube
- IV fluid replacement with NS or LR ( since the fluid lost from the gut is isotonic)
- Add K+ to IV fluids after renal function confirmed
- Analgesics for pain control
Surgery if obstruction does not improve within 24 hrs
Parenteral nutrition may be needed to correct nutritional deficits
Surgery resecting of obstruction & anastomosing the remaining healthy bowel
Partial or total colectomy, colostomy, or ileostomy may be required
What are the principles of nursing management with intestinal obstruction?
Determine location, duration, intensity, and frequency of abdominal pain, and whether abdominal tenderness or rigidity is present
Record the onset, frequency, color, odor, & amount of vomitus
Inspect the abdomen for scars, visible masses & distention
Auscultate for BS, document character & location
Assess bowel function, including passage of flatus
Measure abdominal girth, and palpate for muscle guarding and tenderness which are signs of peritoneal irritation and are indicative of strangulation
Maintain a strict I & O
Foley (report output less than 0.5ml/kg of body weight per hour because it signals inadequate vascular volume and the potential for acute renal failure)
Rising BUN and creatinine indicates sign of renal failure
If HCP decides to wait and see if obstruction resolves on its own, assess the abdomen regularly and monitor for severe abdominal pain, leukocytosis, fever and tachycardia
What defines acute and chronic diarrhea?
Diarrhea is passage of at least 3 loose or liquid stools per day.
Chronic is if it lasts greater than 4 weeks
Not a disease, but a symptom.
Means different things to different patients
What are the possible pathologies?
Decreased fluid absorption
Increased fluid secretion
What are different causes of diarrhea?
- E coli (uncooked beef or chicken, fruits and vegetables grown in manure fertilized soil)
- Salmonella (undercooked eggs or chicken)
- Clostridium difficile, often from antibiotics destroying normal intestinal flora, CONTACT ISOLATION!, must wash hands w/ soap and water, must place in a private room
- Giardia lamblia (drinking water from contaminated lakes or pools)
What are the clinical manifestations of diarrhea?
May be acute or chronic
Acute diarrhea most commonly results from infection
- Poor skin turgor
Acute diarrhea in the adult is usually self-limiting & continues until the irritant or cause is excreted
People can remain contagious for 2 weeks after viral diarrhea
What are the complications of prolonged diarrhea?
- It persists for more than 2 weeks
- When it subsides & returns more than 2-4 weeks after initial episode
Severe diarrhea may be debilitating & life-threatening
- Electrolyte disturbances (hypokalemia)
One of the major causes of death throughout the world
Very hard on the elderly or immune-suppressed, can kill them
What are the main diagnostics a nurse should anticipate for diarrhea?
Thorough pt history and physical exam
- Describe the character of the stools and any associated symptoms.
- Any travel, medication use (OTC), diet, previous surgery, interpersonal contacts, family history
- Blood count to identify infection, anemia, iron, & folate deficiencies
- Elevated liver enzyme levels
- Electrolyte disturbances
- BUN/CREAT deficiencies
- Blood, mucous, WBC’s, parasites
- Stool cultures
- Stool electrolytes, pH, & osmolality
- Stool fat & undigested muscle fibers
Endoscopy to examine mucosa
Upper & lower radiologic studies with barium contrast
What treatment measures should a nurse anticipate for a patient w/ diarrhea?
Based on the cause
Foods and meds that cause diarrhea should be avoided
Aimed at replacing fluid & electrolytes & decreasing number, volume, & frequency of stools
Oral solutions (Gatorade, Pedialyte, etc) for mild diarrhea
Severe diarrhea may require parenteral nutrition (fluids, electrolytes, vitamins)
What medicines should a nurse anticipate administering to a patient w/ diarrhea?
- Once the cause has been determined
- Contraindicated in infectious diarrhea b/c they prolong exposure to the infectious organism
- Inhibit GI motility, decrease intestinal secretions and decrease CNS stimulation of the GI tract
- Pepto bismol
Antispasmotics to help with abdominal cramping
Antibiotics for treating specific organisms
- Clostridium Difficile (should place the client in a private room with contact isolation)
- Vancomycin or Flagyl
What interventions should a nurse implement w/ the patient w/diarrhea?
All cases of diarrhea should be considered infectious until cause is known
Strict infection control precautions
Good hand washing before and after contact with pt
Flush vomitus and stool in toilet
Wash contaminated clothes immediately with soap and hot water
Discuss proper food handling, cooking and storage
C Difficile hard to kill. Alcohol based and ammonia based hand cleaners are ineffective —use soap and water!
- Must use 10% bleach solution to clean room
- Have to be put in isolation
- Disposable equipment, even stethoscope
- Visitors and hosp staff must be gowned and masked
What characterizes constipation?
A decrease in frequency of bowel movements from what is “normal”
Frequency varies from 3 per day to 1 every 3 days
Also includes difficulty passing stools, decrease in stool volume and retention of feces in the rectum
Daily bowel movement is not necessary
What are some common causes of constipation?
Insufficient dietary fiber
Inadequate fluid intake
Decreased physical activity
Ignoring the urge to defecate - causes the muscles in the rectum to become insensitive to the presence of feces. The prolonged retention of feces results in drying of the stool due to water absorption. The harder and drier the feces, the more difficult it is to expel
Medications like opioids
DM, Parkinson’s & MS slow GI transit time
Depression and stress
Some people believe that if they do not have a BM every day then they are constipated, which leads to chronic laxative use and cathartic colon syndrome (the colon becomes dilated and atonic). Ultimately the person loses the ability to defecate without the use of a laxative
What are the clinical manifestations of constipation?
Varies from chronic discomfort to acute abdominal pain
Stools are absent or hard, dry and difficult to pass
Increased rectal pressure
What are some complications of constipation?
- Abdominal pain
- N & V
Rectal mucosal ulcers and fissures
Valsalva maneuvers (straining to defecate) may be fatal for patients with heart failure. During straining the patient inhales deeply and holds breath while contracting abdominal muscles and bearing down. This increases both intraabdominal and intrathoracic pressures and reduces venous return to the heart. The heart rate drops causing the cardiac output to decrease and arterial pressure to decrease. When the patient relaxes, the thoracic pressure falls, resulting in a sudden flow of blood into the heart, tachycardia and an immediate rise in arterial pressure. This sudden change can be fatal to individuals who can not compensate for the sudden return of blood to the heart.
What diagnostic procedures are used with constipation?
Thorough history and PE: Ask the patient about usual defecation patterns and habits, diet, exercise, use of laxatives
What are some treatment options for constipation?
Increasing dietary fiber àEat 20-30 g fiber/day
Increasing fluid intake (2000mL daily) Avoid caffeine- it stimulates fluid loss thru urination
Exercise- walk, swim or bike 3 Xs a week. Also do abdominal exercises to strengthen core
Laxatives- do not overuse
Enemas-do not overuse
Stool softeners are used to prevent
Do not delay defecation
Establish a regular time to defecate
What are two nursing interventions for hernia patients?
Wear truss and NO coughing post-op