INTERFERENCES WITH ELIMINATION

CONGENITAL OBSTRUCTIVE INTERFERENCESAnorectal MalformationsDefinition: malformation of anus and/or rectum minor to severe forms-rectal atresia -imperforate anus

Assessment May Include:

- failure to pass meconium stool ( imperforate anus)

- stools in urine ( fistula)

- ribbonlike stools (anal stenosis)

Inspection of perineal area for abnormalities

Insert lubricated rectal thermometer short distance(check protocol of agency)

Interventions- corrective surgery (anoplasty)- perform manual dilation as ordered- instruct parents in proper technique- prevent infection keeping anal area as clean as possible

HIRSCHSPRUNGS DISEASE:AGANGLIONIC MEGACOLON

Definition/Pathophysiology autonomic parasympathetic ganglion cells absent in part of the large colon resulting in decreased motility, causing mechanical obstruction

-familial disease, more common in boys and associated with Down’s syndrome

Diagnosis: - history of bowel patterns

- radiographic contrast studies

- rectal biopsy to check for ganglion cells

AssessmentNewborns: failure to pass meconium, refusal to suck, abdominal distention and bile stained emesisOlder Child: failure to gain weight and delayed growth, abdominal distention, constipation alternating with diarrhea and vomiting

Treatment/InterventionsSurgical removal of aganglionic bowel with a temporary colostomy (in severe cases)

Milder case: dietary modification ( low residue), stool softeners-isotonic irrigations to prevent impactions

Nursing ManagementIdentify early through history

Monitor fluid & lyte balance; nutrition

Patient education- teach ostomy care if needed- teach how to perform irrigations- teach how to prevent skin breakdown- teach proper nutrition

Post op care/measures: monitor for infection,pain control, measure abdominal circumference,maintain hydration

VOLVULUS

Definition/Pathophysiology: bowel twists upon itself causing obstruction and necrosis

Assessment: nausea, vomiting, no bowel sounds,severe gripping pain and a tense distended abdomenConfirmed by x-ray

Treatment/Interventionssurgical intervention with a bowel resection follow with post op care

INTUSSUSCEPTIONDefinition/Pathophysiology:

- telescoping of the bowel into itself

- usually at the ileocecal valve

- causes inflammation and edema

-blood flow becomes decreased

- commonly in boys (2 months to 5 yrs old) -associated with cystic fibrosis and celiac disease

Assessment: abrupt onset with acute abdominal pain, vomiting and the passage of brown stool

- as condition worsens stools become red andresemble currant jelly

- possibly a palpable mass in R upper quadrantor mid upper abdomen

Diagnosis: history of child and radiography, ultra-sound of abdomen and/or barium enema

Treatments

-Barium Enema can reduce telescoping by hydro-static pressure

-Surgery to reduce invaginated bowel and removenecrotic tissue

Nursing Management for Intussusception

IV’s started immediatelyPost Op -monitor VS, bowel sounds -monitor abdominal distention -check for S&S of infection-manage pain- maintain NGT patencyPATIENT EDUCATION

Omphalocele Definition/Pathophysiology: -congenital malformation where intra- abdominal contents

herniate through the umbilical cord -covered by translucent sac-peritoneum

-may have other congenital anomalies

Nursing Management-cover with NS soaked gauze & cover with plastic-monitor VS especially temp-NPO with IV’s to maintain fluid & lyte balance

Post Op Care

prevent infection

maintain fluid & lytes

control pain

ensure adequate nutritional intake

support parents in dealing with crisis

Hernias Definition: -protrusion of viscus from its normal

cavity through an abnormal openingTypes: Reducible: can be manually placed back into

abdominal cavity

Irreducible: cannot be placed back into cavity

Inguinal: weakness of abdominal wall- spermatic cord emerges in males- round ligament in females

Strangulated: irreducible with blood flow cut off

Treatment/Interventionsmanual reductionuse of supports (TRUSS)surgery for strangulated hernia repair

Nursing Interventions -Post op prevent bladder distention splint incision site deep breathe Q 2 HR (avoid coughing) ice to scrotal area & support avoid heavy lifting 4-6 weeks report pain or difficulty urinating

INFLAMMATORY INTERFERENCES

Necrotizing Enterocolitis -inflammatory disease of the intestinal tract r/t intestinal ischemia, infection, gut immaturity - primarily in premature infants

Assessment -feeding intolerance ( vomiting, abdominal distention, irritability)

-bloody diarrhea - possible sepsis

Diagnostics-X-rays showing free peritoneal gas-bowel wall thickening

Interventions: - NPO and maintain IV’s - NGT to suction - antibiotics

- bowel resection- possible ileostomy, colostomy

NURSING MANAGEMENT

• ID early (monitor feedings)• Maintain fluid & lyte balance• Comfort infant (holding, pacifier to meet

sucking needs)• Patient Education post op

APPENDICITISDefinition

- inflammation of the vermiform appendix preventing mucus from passing into the cecum

-untreated can cause ischemia, gangrene, rupture and peritonitis (may be caused by mechanical obstruction or anatomical defect)

Assessment - low grade fever - Rt. Lower quadrant pain (McBurney’s point) - vomiting, diarrhea, constipation

- rebound tenderness - Rovsing’s sign: palpate Lt. abdomen, pain felt on Rt.

Diagnostics - increased WBC count - CAT scan

Figure 24–16 Common location of pain in children and adolescents with appendicitis.

TREATMENTS/INTERVENTIONS

Pre Op Post OpNPO check VS, monitor incisionIV’s IV’sAntibiotics antibioticsNGT (if peritonitis) coughing & deep breathingNo laxatives drain (penrose) if ruptured

Ruptured Appendix - fever - sudden relief of pain

-chills, pallor

NURSING MANAGEMENT-Promote comfort: Rt. Side lying, semi- fowler’s with knees bent, analgesics-Maintain hydration: I&O, skin turgor-Support respiratory function: cough, deep breathe / splint-Check for S&S of infection:

check incision, check drainage, change dressing, antibiotics

Discharge teaching: -how to check for infection-no strenuous activities

INFLAMMATORY BOWEL DISEASECROHN’S DISEASE

Definition - chronic, inflammatory process along the GI tract - involves all layers of the bowel

(deep fissures & ulcerations may develop between loops of bowel or nearby organs) - possible genetic association

Assessment - crampy abdominal pain (RLQ) - fever - diarrhea (weight loss )

- ileum involvement ( steatorrhea)

(prevalent in individuals of Jewish descent between the ages of 15- 25 yrs. old )

Diagnostics

- CBC: increased WBC, decreased H&H - increased ESR

- hypoalbumineria- abdominal tenderness- thrombocytosis- radiologic & biopsy examination- lower endoscopy (proctosigmoidoscopy)- barium study of UGI tract- CAT scan

ULCERATIVE COLITIS

Definition -chronic disease of colon/rectal mucosa

- can involve entire length of bowel -only involves mucosa/submucosa with ulcerations & inflammation

- emotional/psychosocial factors may have an effect-peak incidence 15 – 25 yrs & 55- 65 yrs. Old F>M

Assessment- bloody/mucus diarrheal stools- lower abdominal pain (cramping) -tenesmus- wt. loss (possible delayed growth & arthralgias)- ID nutritional deficiencies

Diagnostics -ID the extent of involved bowel - r/o any infectious process

(i.e. Shigella) - radiologic studies & endoscopy

with biopsy - decreased H&H, albumin -increased WBC

Treatment/ManagementMedications Salicylate Compounds: Sulfasalazine Corticosteroids: prednisone Immunosuppressants: cyclosporine Antidiarrheals: immodium Antibiotics : ciprofloxacilNutrition Therapy - low fiber diet - if poor appetite (high protein) -supplemental vitamins, iron, zinc & folic acid -TPN

Ulcerative Colitis Crohn’s

Temporary colostomy/ileostomy bowel resection

DIFFERENTIAL FEATURES OF U. C. AND CROHN’S

FeatureFeature Ulcerative Ulcerative ColitisColitis

Crohn’s DiseaseCrohn’s Disease

LocationLocation Begins in rectumBegins in rectum

Proceeds to cecumProceeds to cecumUsually terminal Usually terminal ileumileum

w/ patchy w/ patchy involvement involvement through all bowel through all bowel layerslayers

EtiologyEtiology UnknownUnknown UnknownUnknown

Peak Peak IncidenceIncidence

15-25 & 55-6515-25 & 55-65 15 - 4015 - 40

StoolsStools 10-20 liquid, bloody10-20 liquid, bloody

stoolsstools5-6 soft, loose 5-6 soft, loose stoolsstools

Per day, rarely Per day, rarely bloodybloody

Common Common

ComplicationsComplicationsHemorrhageHemorrhage

PerforationPerforation

FistulasFistulas

Nutritional Nutritional DeficienciesDeficiencies

FistulasFistulas

Nutritional Nutritional DeficienciesDeficiencies

wt. losswt. loss moderatemoderate severesevere

GASTROENTERITIS (ACUTE DIARRHEA)Definition

- inflammation of the stomach and intestines

-may be accompanied by vomiting and diarrhea (bacterial or parasitic infections)Assessment

-mild, moderate or severe diarrhea (loose, watery stools) - irritabilty, cramping - nausea and vomiting - fluid & lyte balance - hx & physical exam of patient - stool examination (ova and parasite)

Treatments/Interventions-ID the causative factor-moderate: maintain fluid & lytes balance-oral replacement therapy

(pedialyte, gatorade) -no carbonated or sugar drinks

-severe: keep NPO; give IV fluids (NS/ RL) - start with clear liquids - monitor lytes especially potassium for

cardiac patients - antidiarrheals for adults

Nursing Interventions -Provide emotional support : allow pt. to talk

-Provide rest and comfort: quiet environment-Ensure adequate nutrition: BRAT diet

(bananas, rice, applesauce & toast)CRAM (complex carbohydrates

rice and milk)milk free for 48 hrs.; caffeine free

Discharge planning: teach parents S&S of dehydration

DIVERTICULITISDefinition/Pathophysiology: -a saclike outpouching of the lining of the bowel

(If bowel contents are retained in the sac, it becomes inflamed or infected)

Assessment: -chronic constipation-abdominal pain (especially LLQ)-fever-abdominal distention/tenderness

Diagnostics:- Ultrasonography-barium enema( not during acute phase)-increased ESR & WBC-decreased H&H-colonoscopy (after acute phase)

Complications:-possible peritonitis- abscess formation & bleeding

Treatment/ManagementDietary: -Severe stage: NPO, NGT, IV’s -During inflammation: low fiber clear liquids initially -After inflammation: high fiber -Avoid foods with seeds, nuts, alcohol -Rest

Medications-Broad spectrum antibiotics (Flagyl, Cipro)- Mild analgesics

- Anticholinergics (pro banthine)- Bulk forming laxatives (metamucil)

Surgical Managementperitonitis or abscess formations may require surgery - one stage: bowel resection - multistaged: bowel resected and temporary colostomy performed

Nursing Managementteach pt. about dietary modificationsteach pt. about the various medsteach pt. about ostomy care if needed

PARALYTIC ILEUSDefinition/Pathophysiology: paralysis of peristaltic movement due to effect of trauma or toxins on the nerves that regulate intestinal movement

Assessment-abdominal pain/distention: accumulation of gas/fluid above the obstruction-rigid abdomen: increased distention makes it rigid-vomiting: earliest sign of high obstruction; bile if lower obstruction- constipation-absent bowel sounds: no peristalsis with obstruction-shock: loss of fluid/lytes from the bloodstream into intestines

IRRITABLE BOWEL SYNDROMEDefinition: functional disorder of intestinal mobility with no irritation (spasms)

Assessment: symptoms range from mild to severe in intensity with constipation, diarrhea or both - pain, cramps (LLQ) - bloating, abdominal distention -more females than males

Treatment/ManagementDietary modifications: ID food intolerances

limiting caffeine and avoiding alcohol -dietary fiber and bulk help stools

Medications -bulk forming laxatives (metamucil) -antidiarrheal agents (Lomotil) -anticholinergic agents (Bentyl) -tricyclic antidepressants (Elavil)-5-HT4 (Zelnorm)

Stress Management

Diagnostics: CT scan, possible endoscopy

Treatment/InterventionsNPONGTNasointestinal tube (Cantor/Harris tube

with mercury)IV’sPain managementTreat shock

Nursing InterventionsID earlyMonitor pt. and all tubesMaintain accurate I&O with monitoring of lytes

Table 24–2 Causes of diarrhea in children.

HEMORRHOIDSDefinition/Pathophysiology

- hyperplastic areas of vascular tissue in the anal canal - Internal hemorrhoids above the internal sphincter - External hemorrhoids outside the external sphincter.

AssessmentInternal: prolapse causing discomfortExternal

-itching - pain - bright red bleeding with defecation

Treatment/InterventionsConservative measures: increase fiber diet

(fruit, bran, whole grains)-encourage plenty of water-analgesic ointments, suppositories-stool softeners-Sitz baths

Teach to avoid irritating laxatives, spicy foods, caffeine, alcohol, nutsSurgery

Pre op: enemas & laxativesPost op: monitor rectal bleeding report significant bloody drainage side lying position

Nursing Interventions

-flotation pad-pain med before BM-stool softener-increased fiber in diet-sitz bath-perianal care

Table 24–3 Influential factors in childhood constipation.

CONSTIPATIONDefinition

- decrease in the number of stools - stools become hard and dry - may even have oozing of liquid stool around impaction.

Causes Medications: opoids, iron Obstruction: tumors Neuromuscular condition: Multiple Sclerosis Dietary habits: decreased fiber and fluid intake

AssessmentAbdominal distention with painPressure strainingHeadacheFatigue

ComplicationsHypertensionFecal impactionHemorrhoids and fissuresStraining causing Valsalva Manuever

TreatmentTreat underlying causeIncrease fiber & fluid in dietBowel habit trainingMedication: stool softeners ( colace)

bulk forming agent (metamucil)stimulants (dulcolax)

Nursing InterventionsTeach change in life style habits

PARASITIC INFECTIONS (see Ball & Bindler )Definition/Pathophysiology A parasite is an organism that lives in, on or at the expense of a host. Common GI parasites disorders include giardia, enterobiasis and ascariasis.Assessment

Giardiasis(Giardia)S&S: diarrhea Treatment: vomiting furazolidine

anorexia quinicrine

Enterobiasis (Pinworm)S&S: perianal itching Treatment:

irritability antihelminthic meds- restlessness mebendazole

pyrantel pamoate

Ascariasis ( Roundworm)S&S TreatmentSevere can cause intestinal same as above obstructionPeritonitisLung involvement

InterventionsPatient Teaching

Preventative measures Proper hygiene Careful handwashingMedication Education

Practice Question

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child’s record and expects to note which symptom of this disorder documented?

A. watery diarrhea B. ribbon-like stools C. profuse projectile vomiting D. bright red blood and mucus in the stools

Practice Question

A nurse is reviewing the record of a client with Crohn’s disease. Which of the following stool characteristics would the nurse expect to be documented in the client’s record?

A. chronic constipation B. diarrhea C. constipation alternating with diarrhea D. stool constantly oozing from the rectum