Chapter 59

Care of Patients with Noninflammatory Intestinal Disorders

Mrs. Kreisel MSN, RNNU130 Adult HealthSummer 2011

Lower GI Bleed

Irritable Bowel Syndrome (IBS)

• IBS is a functional GI disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating.

• Manning criteria are present:• Abdominal pain relieved by defecation

or falling asleep• Abdominal pain associated with

changes in stool frequency or consistency

Irritable Bowel Syndrome (Cont’d)

• Abdominal distention• The sense of incomplete evacuation of

stool• The presence of mucus with stool

passage• A flare-up of symptoms usually brings the

patient to the health care provider.

Treatment

• Health teaching—teaching the patient to avoid problem stimulants

• Diet therapy—eliminating offending or upsetting foods• Drug therapy—bulk-forming laxatives, antidiarrheal

agents, 5-HT4 antagonists, M3-receptor antagonists, and tricyclic antidepressants

• Stress management based on the patient’s current and ongoing stressors

• Complementary and alternative therapies used to reduce symptoms and discomfort

Herniation

• Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes

• Types of hernia include:• Indirect inguinal • Direct inguinal • Femoral • Umbilical • Incisional or ventral

Common Abdominal Hernias

Classification of Hernias

• Reducible: When the contents of the hernial sac can be placed back into the abdominal cavity by pressure.

• Irreducible: Also know as incarcerated hernia, cannot be reduced or placed back into the abdominal cavity. Requires emregency surgical evaluation.

• Strangulated: When the blood supply to the herniated segment of the bowel is cut off by pressure from the hernial ring (the band of muscle around the hernia).

• WHAT NURSING CONSIDERATIONS ARE IMPORTANT FOR THIS TYPE OF HERNIA?

Nonsurgical Management

• Truss: For people not able to undergo surgery and is mainly for males.

• It is a pad made with firm material and is held inplace over the hernia with a belt to keep the abdominal contents from protruding into the hernia sac.

• The surgeon must reduce the hernia if it is not incarcerated. The patient applies it in the morning.

• Lots of Nursing Education is the priority

Surgical Management

• Preoperative care—NPO day of surgery• Operative procedures:

• Minimally invasive inguinal hernia repair (MIIHR) (herniorrhaphy)

• Hernioplasty• Open or conventional herniorrhaphy

Postoperative Care

• After open surgical approach, have patient avoid coughing.

• After indirect inguinal hernia repair, a scrotal support and use of ice bags to the scrotum may be used to prevent swelling. Elevation of the scrotum on a soft pillow helps prevent and control swelling.

• Difficulty voiding.

Colorectal Cancer (CRC)

• Colorectal refers to the colon and the rectum, which together make up the large intestine.

• Most CRCs are adenocarcinomas.• Etiology:

• Age older than 50 years• Genetic predisposition• Personal or family history of cancer• Familial (disease that occurs more in a family then

would be expected by chance) adenomatous (glandular tissue over growths) polyposis (the presence of numerous polyps)

Colorectal Cancer (Cont’d)

Health Promotion and Maintenance

• Genetic testing for FAP (familial adenomatous polyposis)and HNPCC (herediary nonpolyposis colorectal cancer)

• Diet modification• Colon cancer screening• Aspirin therapy• Dietary calcium supplements

Clinical Manifestations

• Most common signs—rectal bleeding, anemia, and a change in the stool.

• The clinical manifestations of colon rectal cancer depend on the location of the tumor.

Laboratory Assessment

• Hemoglobin and hematocrit values usually decreased• Fecal occult blood test• Possible elevation of carcinoembryonic antigen• Imaging assessment• Other diagnostic tests• Genetic counseling

Nonsurgical Management

• American Joint Committee on Cancer • Stage I—tumor invades up to muscle layer• Stage II—tumor invades up to other organs or perforates

peritoneum• Stage III—any level of tumor invasion and up to 4

regional lymph nodes• Stage IV—any level of tumor invasion; many lymph

nodes affected with distant metastasis

Nonsurgical Management (Cont’d)

• Radiation therapy• Drug therapy

Surgical Management

• Colon resection• Colectomy• Abdominoperineal (AP) resection • Colostomy• Minimally invasive surgery

Surgical Management (Cont’d)• Preoperative care includes:

• Consultation with enterostomal therapist• Discussions with surgeon of risk for sexual and

urinary dysfunctions• Bowel prep• Nasogastric tube and IV line placed for use after

surgery• Assignment of case manager for long-term

consequences

Colostomies

Surgical Management

• Operative procedures• Postoperative care

Nursing Interventions:

PRIMARY: Assess the meaning and effect of cancer as perceived by the client!

Colostomy Care• Normal appearance of the stoma• Signs and symptoms of complications• Measurement of the stoma• Choice, use, care, and application of appropriate

appliance to cover stoma• Measures to protect the skin• Dietary measures to control gas and odor• Resumption of normal activities

Intestinal Obstruction

• Mechanical obstruction• Nonmechanical obstruction, also known as paralytic

ileus or adynamic ileus• Strangulated obstruction resulting from tumors, hernias,

fecal impactions, strictures, intussusception, volvulus, fibrosis, vascular disorder, and adhesions

Mechanical Obstruction

Clinical Manifestations of Mechanical Obstruction

• Midabdominal pain or cramping• Vomiting• Obstipation (extreme constipation)• Diarrhea• Alteration in bowel pattern and stool• Abdominal distention• Absence of Borborygmi (a gurgling, splashing sound

normally heard over the large intestine; caused by gas passing through the liquid contents of the intestine)

• Abdominal tenderness

Clinical Manifestations of Nonmechanical Obstruction

• Constant, diffuse discomfort• Abdominal distention• Decreased to absent bowel sounds• Vomiting• Obstipation

Assessment

• Laboratory assessment• Imaging assessment• Other diagnostic tests

Nonsurgical Management

• Nothing by mouth• Nasogastric tube placement• Nasointestinal tubes• IV fluid replacement and maintenance• Mouth care• Pain management• Drug therapy

Surgical Management

• Exploratory laparotomy• Preoperative care• Operative procedure• Postoperative care

Abdominal Trauma

• Injury to the structures located between the diaphragm and the pelvis, which occurs when the abdomen is subjected to blunt or penetrating forces

• Organs may include the large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary bladder

• Blunt abdominal trauma, which often occurs in motor vehicle accidents

• Penetrating abdominal trauma caused by gunshot wounds, stabbing

Assessment • Assess airway, breathing, and circulation• Assess for:

• Hypovolemic shock• Cullen’s sign: bluish discoloration of the periumbilical

skin due to intraperitoneal hemorrhage.• Turner’s sign: : bluish discoloration on the flank may

indicate retroperitoneal bleeding into the abdominal wall• Ballance’s sign: pt on Left side and do percussion. Left

flank dullness and resonance over the right flank• Kehr’s sign: Left shoulder pain resulting from

diaphragmatic irritation as seen in spleen injury.

• Dullness over hollow organs like the stomach or intestines may mean blood or fluid in that area.

Abdominal Trauma: Emergency Care

• Two large-bore IV lines are placed• Central venous catheter• Type and crossmatch 4 to 8 units of blood• Balanced saline solution, crystalloids, and

possibly blood• Arterial blood gas assessment• Fluid and electrolyte management• Continuous hemodynamic monitoring• Surgical management

Polyps

• Small growths in the intestinal tract that are covered with mucosa and are attached to the surface of the intestine

• Various types• Familial adenomatous polyposis• Usually asymptomatic, but can cause gross rectal

bleeding, intestinal obstruction, and intussusception• Nursing care

Polyps (Cont’d)

Hemorrhoids

• Unnaturally swollen or distended veins in the anorectal region

• Internal hemorrhoids• External hemorrhoids • Nonsurgical management• Surgical management—hemorrhoidectomy

Malabsorption Syndrome

• Syndrome associated with a variety of disorders and intestinal surgical procedures

• Primary clinical manifestations—diarrhea and steatorrhea

• Interventions:• Dietary management• Surgical or nonsurgical management• Drug therapy

•NCLEX TIME

Question 1

How many Americans are estimated to suffer from irritable bowel syndrome?

A. 7% to 12% B. 10% to 22%C. 25% to 33%D. 35% to 40%

Question 2

What symptom does the nurse expect the patient with intussusception to exhibit?

A. Decrease in pulseB. Extremely elevated body temperatureC. Singultus (hiccups)D. Frequent bloody stools

Question 3

What is a priority nursing intervention in the care of a patient with chronic diarrhea?

A. Keep the skin clean and dry. B. Use medicated wipes rather than washcloths to clean

the perineal area.C. Consult a nutritionist for suggested fibers to add to

the diet.D. Review the patient’s medications that may be

exacerbating the diarrhea.

Question 4

A 21-year-old female college student presents to the clinic complaining of lower abdominal pain, constipation and diarrhea, and belching and bloating sensation. The most likely cause of her symptoms is:

A. AppendicitisB. Diverticular diseaseC. Irritable bowel syndrome D. Mental health disorder

Question 5

What percentage of people develop polyps or colorectal tumor by age 70 years?

A. 10%B. 25%C. 40%D. 50%