Management of Patients with Intestinal and Rectal Disorders

Constipation

• Abnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem

• Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intraabdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise

• Increased risk in older age• Perceived constipation: a subjective problem in which the patient’s elimination pattern is not

consistent with what he or she believes is normal

Complications

• Hypertension• Fecal impaction• Hemorrhoids• Fissures• Megacolon

Patient Learning Needs

• Normal variations of bowel patterns• Establishment of normal pattern• Dietary fiber and fluid intake• Responding to the urge to defecate• Exercise and activity• Laxative use• See Chart 38-1

Diarrhea

• Increased frequency of bowel movements (more than 3 per day), increased amount of stool (more than 200 g per day), and altered consistency (ie, looseness) of stool

• Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors

• May be acute or chronic• Causes include infections, medications, tube feeding formulas, metabolic and endocrine

disorders, and various disease processes

Manifestations

• Increased frequency and fluid content of stools• Abdominal cramps• Distention• Borborygmus• Painful spasmodic contractions of the anus• Tenesmus

Complications

• Fluid and electrolyte imbalances • Dehydration • Cardiac dysrhythmias

Patient Learning Needs

• Recognition of need for medical treatment• Rest• Diet and fluid intake• Avoid irritating foods (caffeine, carbonated beverages) and very hot and cold foods• Perianal skin care• Medications• May need to avoid milk, fat, whole grains, fresh fruit, and vegetables • Lactose intolerance: see Chart 38-2

Malabsorption

• The inability of the digestive system to absorb one or more of the major vitamins, minerals, and nutrients

• Conditions: see Table 38-2– Mucosal (transport) disorders– Infectious disease– Luminal disorders– Postoperative malabsorption– Disorders that cause malabsorption of specific nutrients

Diverticular Disease

• Diverticulum: sac-like herniations of the lining of the bowel that extend through a defect in the muscle layer

• May occur anywhere in the intestine, but are most common in the sigmoid colon • Diverticulosis: multiple diverticula without inflammation • Diverticulitis: infection and inflammation of diverticula • Diverticular disease increases with age and is associated with a low-fiber diet • Diagnosis is usually by colonoscopy

Nursing Process—Assessment of the Patient With Diverticulitis

• Patients may have chronic constipation preceding development of diverticulosis, frequently asymptomatic but may include bowel irregularities, nausea, anorexia, bloating, and abdominal distention

• With diverticulitis, symptoms include mild or severe pain in lower left quadrant, nausea, vomiting, fever, chills, and leukocytosis

• Determine the onset and duration of pain, and past and present elimination patterns • Encourage nutrition that includes fiber intake • Inspect stool and monitor for symptoms of potential complications

Nursing Process—Diagnosis of the Patient With Diverticulitis

• Patients may have chronic constipation preceding development of diverticulosis, frequently asymptomatic but may include bowel irregularities, nausea, anorexia, bloating, and abdominal distention

• With diverticulitis, symptoms include mild or severe pain in lower left quadrant, nausea, vomiting, fever, chills, and leukocytosis

• Determine the onset and duration of pain, and past and present elimination patterns • Encourage nutrition that includes fiber intake • Inspect stool and monitor for symptoms of potential complications

Nursing Process—Diagnosis of the Patient With Diverticulitis

• Constipation• Acute pain

Collaborative Problems/Potential Complications• Perforation• Peritonitis• Abscess formation• Bleeding

Nursing Process—Planning the Care of the Patient With Diverticulitis

• Major goals include attainment and maintenance of normal elimination patterns, pain, relief, and absence of complications

Maintaining Normal Elimination Pattern

• Encourage fluid intake of at least 2 L/d• East soft foods with increased fiber, such as cooked vegetables• Participate in an individualized exercise program• Use bulk laxatives (psyllium) and stool softeners

Inflammatory Bowel Disease (IBD)

• Regional enteritis (Crohn’s disease) • Ulcerative colitis• See Table 38-4

Nursing Process—Assessment of the Patient With Inflammatory Bowel Disease

• Perform health history to identify onset, duration, and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history

• Discuss dietary patterns, alcohol, caffeine, and nicotine use• Assess bowel elimination patterns and stool• Perform abdominal assessment

Colorectal Cancer • The third most common cause of U.S. cancer deaths • Risk factors: see Chart 38-8• Importance of screening procedures• Manifestations include change in bowel habits; blood in stool—occult, tarry, bleeding; tenesmus;

symptoms of obstruction; pain, either abdominal or rectal; feeling of incomplete evacuation• Treatment depends upon the stage of the disease

Gastritis

• A common GI problem that causes inflammation of the stomach• Acute: rapid onset of symptoms usually caused by dietary indiscretion. Other causes include

medications, alcohol, bile reflux, and radiation therapy. Ingestion of strong acid or alkali may cause serious complications.

• Chronic: prolonged inflammation due to benign or malignant ulcers of the stomach or Helicobacter pylori. May also be associated with some autoimmune diseases, dietary factors, medications, alcohol, smoking, and chronic reflux of pancreatic secretions or bile.

Manifestations of Gastritis

• Acute: abdominal discomfort, headache, lassitude, nausea, vomiting, and hiccupping • Chronic: epigastric discomfort, anorexia, heartburn after eating, belching, sour taste in the mouth,

nausea, vomiting, and intolerance of some foods; may cause vitamin deficiency due to malabsorption of B12

• May be associated with achlorhydria, hypochlorhydria, and hyperchlorhydria • Diagnosis is usually by UGI x-ray or endoscopy and biopsy

Medical Management of Gastritis

• Acute– Refrain from alcohol and food until symptoms subside– If due to strong acid or alkali treatment to neutralize the agent, avoid emetics and lavage

due to danger of perforation and damage to the esophagus– Supportive therapy

• Chronic– Modify diet, promote rest, reduce stress, and avoid alcohol and NSAIDs– Pharmacologic therapy: see Table 37-1

Peptic Ulcer

• Erosion of a mucous membrane forms an excavation in the stomach, pylorus, duodenum, or esophagus

• Associated with infection of H. pylori• Risk factors include excessive secretion of stomach acid, dietary factors, chronic use of NSAIDs,

alcohol, smoking, and familial tendency• Manifestations include a dull gnawing pain or burning in the midepigastrium; heartburn and

vomiting may occur• Treatment includes medications, lifestyle changes, and occasionally surgery: see Tables 37-1 and

37-3

Nursing Process—Assessment of the Patient With Gastritis

• History including presenting signs and symptoms• Dietary history and dietary associations with symptoms• Monitor dietary intake and keep 72-hour diet diary• Abdominal assessment

Nursing Process—Diagnosis of the Patient With Gastritis

• Anxiety• Imbalanced nutrition• Risk for fluid volume imbalance• Deficient knowledge• Acute pain

Nursing Process—Planning the Care of the Patient With Gastritis

• Major goals include reduced anxiety, avoidance of irritating foods, adequate intake of nutrients, maintenance of fluid balance, increased awareness of dietary management, and relief of pain

Interventions• Reduce anxiety; use calm approach and explain all procedures and treatments• Promote optimal nutrition. For acute gastritis, the patient should take no food or fluids by mouth;

introduce clear liquids and solid foods as prescribed. Evaluate and report symptoms. Discourage caffeinated beverages, alcohol, and cigarette smoking. Refer patient for alcohol counseling and smoking cessation.

• Promote fluid balance; monitor I&O for signs of dehydration, electrolyte imbalance, and hemorrhage

• Measures to relieve pain: diet and medications• See Chart 37-1

Nursing Process—Assessment of the Patient With Peptic Ulcer• Assess pain and methods used to relieve pain • Lifestyle and habits such as cigarette and alcohol use• Provide medications, including use of NSAIDs• Monitor for signs and symptoms of anemia or bleeding• Provide abdominal assessment

Nursing Process—Diagnosis of the Patient With Peptic Ulcer

• Acute pain• Anxiety• Imbalanced nutrition• Deficient knowledge•

Nursing Process—Planning the Care of the Patient With Peptic Ulcer

• Major goals for the patient may include relief of pain, anxiety reduction, maintenance of nutritional requirements, knowledge about the management and prevention of ulcer recurrence, and absence of complications

Anxiety

• Assess anxiety • Maintain calm manner • Explain all procedures and treatments• Help identify stressors • Explain various coping and relaxation methods such as biofeedback, hypnosis, and behavior

modification•

Patient Teaching

• Medication usage• Dietary restrictions• Lifestyle changes• See Chart 37-2

Management of Potential Complications

• Management of hemorrhage– Assess for evidence of bleeding, hematemesis, or melena, and symptoms of

shock/impending shock and anemia– Treatment includes IV fluids, NG, and saline or water lavage; oxygen; treatment of

potential shock including monitoring of VS and UO; may require endoscopic coagulation or surgical intervention

• Pyloric obstruction– Symptoms include nausea, vomiting, constipation, epigastric fullness, anorexia, and

(later) weight loss– Insert NG tube to decompress the stomach and provide IV fluids and electrolytes; balloon

dilation or surgery may be required• Management of perforation or penetration

– Signs include severe upper abdominal pain that may be referred to the shoulder, vomiting and collapse, tender board-like abdominal, and symptoms of shock/impending shock

– Patient requires immediate surgery

Hepatitis (See Chart 39-6)

• Viral hepatitis: a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes

– A– B– C– D– E– Hepatitis G and GB virus-C

• Nonviral hepatitis: toxin- and drug-induced

Hepatitis A (HAV)• Fecal-oral transmission• Spread primarily by poor hygiene; hand-to-mouth contact, close contact, or through food and

fluids• Incubation: 15-50 days• Illness may last 4-8 weeks.• Mortality is 0.5% for younger than age 40 and 1-2% for those over age 40.• Manifestations: mild flu-like symptoms, low-grade fever, anorexia, later jaundice and dark urine,

indigestion and epigastric distress, enlargement of liver and spleen• Anti-HAV antibody in serum after symptoms appear

Management

• Prevention – Good handwashing, safe water, and proper sewage disposal– Vaccine– See Chart 39-7 – Immunoglobulin for contacts to provide passive immunity

• Bed rest during acute stage• Nutritional support

See Chart 39-8

Hepatitis B (HBV)

• Transmitted through blood, saliva, semen, and vaginal secretions, sexually transmitted, transmitted to infant at the time of birth

• A major worldwide cause of cirrhosis and liver cancer• Risk factors

See Chart 39-9• Long incubation period: 1-6 months• Manifestations: insidious and variable, similar to hepatitis A • The virus has antigenic particles that elicit specific antibody markers during different stages of

the disease. Management

• Prevention– Vaccine: for persons at high risk, routine vaccination of infants– Passive immunization for those exposed– Standard precautions/infection control measures– Screening of blood and blood products

• Bed rest • Nutritional support • Medications for chronic hepatitis type B include alpha interferon and antiviral agents: lamivudine

(Epivir), adefovir (Hepsera).

Hepatitis C

• Transmitted by blood and sexual contact, including needlesticks and sharing of needles• The most common bloodborne infection

• A cause of 1/3 of cases of liver cancer and the most common reason for liver transplant• Risk factors

See Chart 39-10 • Incubation period is variable.• Symptoms are usually mild.• Chronic carrier state frequently occurs.

Management

• Prevention • Screening of blood• Prevention of needlesticks for health care workers • Measures to reduce spread of infection as with hepatitis B• Alcohol encourages the progression of the disease, so alcohol and medications that affect the liver

should be avoided. • Antiviral agents: interferon and ribavirin (Rebetol)

Hepatitis D and E• Hepatitis D

– Only persons with hepatitis B are at risk for hepatitis D.– Transmission is through blood and sexual contact.– Symptoms and treatment are similar to hepatitis B, but patient is more likely to develop

fulminant liver failure and chronic active hepatitis and cirrhosis.• Hepatitis E

– Transmitted by fecal-oral route– Incubation period 15-65 days– Resembles hepatitis A and is self-limited, with an abrupt onset. No chronic form.