Chapter 38 Management of Patients With Intestinal and Rectal Disorders

1. Chapter 38Management of Patients With Intestinal and Rectal Disorders

2. Constipation Abnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem. Perceived constipation: a subjective problem in which the person’s elimination pattern is not consistent with what he or she believes is normal.

3. Constipation Causes • Medications/Chronic laxative use • Weakness/inability to increase intra-abdominal pressure • immobility, fatigue • Diet • Ignoring urge to defecate • lack of regular exercise. • Increased risk in older age

4. Manifestations • Fewer than 3 BMs per week • Abdominal distention • Decreased appetite • Headache • Fatigue • Indigestion • A sensation of incomplete evacuation • Straining at stool • Elimination of small-volume, hard, dry stools

5. Complications • Hypertension • Fecal impaction • Hemorrhoids • Fissures • Megacolon

6. 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 Table 38-1)

7. Laxatives (see Table 38-1) Bulk forming (Metamucil, milk of magnesia) Lubricating (mineral oil, glycerin supp.) Stimulant (Ducolax, Senokot) Softener (Colace) Osmotic agents(Golyte)

8. Diarrhea Increased frequency of bowel movements (more than 3 per day), increase amount of stool (more than 200 g per day), and altered consistency Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors.

9. Diarrhea (causes) • acute or chronic • infections • medications • tube feeding formulas • metabolic and endocrine disorders

10. Manifestations • Increased frequency and fluid content of stools • Abdominal cramps • Distention • Borborygmus • Painful spasmodic contractions of the anus • Tenesmus (constantly feeling the need to pass stool)

11. Complications • Fluid and electrolyte imbalances • Dehydration • Cardiac dysrhythmias (k+ loss) • Altered Skin integrity

12. Patient Learning Needs • Recognition of need for medical treatment • Rest • Diet and fluid intake • Avoid irritating foods—caffeine, carbonated beverages, 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)

13. 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

14. Diverticular Disease Diverticulum: sac-like herniations of the lining of the bowel that extend through a defect in the muscle layer Most common in the sigmoid colon Diagnosis is usually by colonoscopy

15. Diverticular Disease • Diverticulosis: multiple diverticula without inflammation • Diverticulitis: infection and inflammation of diverticula • Diverticular disease increases with age and is associated with a low-fiber diet

16. Nursing Process: The Care of the Patient with Diverticulitis—Assessment • 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.

17. Nursing Process: The Care of the Patient with Diverticulitis—Assessment • Ask regarding the onset and duration of pain, and past and present elimination patterns. • Nutrition and dietary patterns including fiber intake. • Inspect stool and monitor for symptoms potential complications.

18. Nursing Process: The Care of the Patient with Diverticulitis—Diagnoses • Constipation • Acute pain

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

20. Nursing Process: The Care of the Patient with Diverticulitis—Planning Major goals • normal elimination patterns • pain relief • absence of complications.

21. Question Is the following statement True or False? The most common site for diverticulitis is the ileum.

22. Answer False The most common site for diverticulitis is not the ileum. The most common site for diverticulitis is the sigmoid.

23. Maintaining Normal Elimination Pattern • Encourage fluid intake of at least 2 L/d • Soft foods with increased fiber, such as cooked vegetables • Individualized exercise program • Bulk laxatives (psyllium) and stool softeners

24. Inflammatory Bowel Disease (IBD) Crohn’s disease (regional enteritis) Ulcerative colitis See Table 38-4 p 1082

25. Crohn’s Inflammation that extends through all layers Most common in the Ileum and ascending colon Remission and exacerbation

26. Crohn’s Edema and thickening of mucosa making a cobblestone appearance(fistula and abscesses and adhesions) Cause is unknown (once thought to be stress) Complications Small bowel obstruction Cholelithiasis Nephrolithiasis Arthritis

27. Ulcerative Colitis Recurrent ulcerative and inflammatory of mucosa and submucosal layers. Begins in the rectum and spreads Highest incidence in Caucasians and Jewish heritage 5% develop colon cancer

28. Ulcerative Colitis Severe diarrhea Bleeding is common Complications Toxic mega colon Perforation Malignancy

29. Toxic Megacolon • Potentially lethal complication of inflammatory bowel disease (IBD) or infectious colitis that is characterized by total or segmental non-obstructive colonic dilatation plus systemic toxicity • It causes widening (dilation) of the large intestine within 1 to a few days. • The term "toxic" means that this complication occurs with infection or inflammation and is very dangerous.

30. Toxic megacolon • Mucosal inflammation leads sequentially to the release of inflammatory mediators and bacterial products, increased inducible nitric oxide synthase, generation of excessive nitric oxide, and colonic dilatation

31. Toxic megacolon • A physical exam may reveal signs of septic shock. The doctor will notice tenderness in the abdomen and possible loss of bowel sounds.

32. Toxic megacolon Treatment • Fluids and electrolytes to help prevent dehydration and shock. this is usually not enough to reverse the megacolon. • If rapid widening continues perforation surgery (colectomy) • Antibiotics to prevent sepsis (a severe infection).

33. Nursing Process: The Care of the Patient with Inflammatory Bowel Disease—Assessment • Health history to identify • onset, duration and characteristics of pain, • diarrhea, • urgency, tenesmus, • nausea, anorexia, weight loss, • bleeding • family history

34. Nursing Process: The Care of the Patient with Inflammatory Bowel Disease—Assessment • 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 • Abdominal assessment

35. Nursing Process: The Care of the Patient with Inflammatory Bowel Disease— Diagnoses • Diarrhea • Acute pain • Deficient fluid • Imbalanced nutrition • Activity intolerance • Anxiety • Ineffective coping • Risk for impaired skin integrity • Risk for ineffective therapeutic regimen management

36. Collaborative Nursing Problems/Potential Complications • Electrolyte imbalance • Cardiac dysrhythmias • GI bleeding with fluid loss • Perforation of the bowel

37. Nursing Process: The Care of the Patient with Inflammatory Bowel Disease— Planning • Major goals may include attainment of normal bowel elimination patterns, relief of abdominal pain and cramping, prevention of fluid deficit, maintenance of optimal nutrition and weight, avoidance of fatigue, reduction of anxiety, promotion of effective coping, absence of skin breakdown, increased knowledge of disease process and therapeutic regimen, and avoidance of complications.

38. Maintaining Normal Elimination Pattern • Identify relationship between diarrhea and food, activities, or emotional stressors. • Provide ready access to bathroom/commode. • Encourage bed rest to reduce peristalsis. • Administer medications as prescribed. • Record frequency, consistency, character, and amounts of stools.

39. Other Interventions • Assessment and treatment of pain/discomfort, anticholinergic medications (reduce muscle spasm) prior to meals, analgesics, positioning, diversional activities, and prevention of fatigue • Fluid deficit, I&O, daily weight, assessment of symptoms of dehydration/fluid loss, encourage oral intake, measures to decrease diarrhea • Optimal nutrition; elemental feedings that are high in protein and low residue or PN may be needed • Reduce anxiety; calm manner, allow patient to express feelings, listening, patient teaching

40. Patient Teaching • See Chart 38-3 • Verbalize Understanding of disease process • Nutrition/diet (low residue, bland, high protein, high vitamin,) • Medications • Promote fluid electrolyte balance during exacerbations • Stress reduction measures

41. The Patient with an Intestinal Diversion • See Charts 38-4, 38-5, and 38-7 (page 1089) • Preoperative care • Postoperative care • Emotional support • Skin and stoma care • Irrigation of a Kock’s pouch (continent ileostomy).See Chart 38-6 • Diet and fluid intake • Prevention of complications

42. Changing an ostomy http://www.youtube.com/watch?v=Kopk_Hepgvs

43. Question Is the following statement True or False? Abdominal pain and constipation are common clinical manifestations of Crohn’s disease.

44. Answer False Abdominal pain and diarrhea are common clinical manifestations of Crohn’s disease.

45. Intestinal ObstructionsMechanical obstructionFunctional obstructionSmall bowelLarge bowel

46. Causes of Intestinal Obstructions • Intusseption • Volvulus of signmoid colon (counterclockwise twist) c. Hernia (inguinal)

47. Small Bowel Obstruction • Vomiting • Stomach/ intestinal contents bile contents • Then fecal material (darker) • Crampy /colicky pain • Dehydration, drowsiness, malaise • abdominal distention (the lower the bigger) • Hypovolemic shock if not corrected

48. Medical Management • Abdominal x-ray or Ct to diagnose • NG tube to decompress (successful in most cases for partial obstruction) • IV fluids • If complete obstruction =surgery

49. Colorectal cancer

50. Colorectal Cancer • The third most common cause of cancer deaths in the United States. • Risk factors (see Chart 38-9, p 1099). • Importance of screening procedures.