Assessing Clients with Bowel Elimination Disorders

1. Assessing Clients with Bowel Elimination Disorders Chapter 26

2. Review of Anatomy and Physiology Small intestine pyloric sphincter to ileocecal junction three regions duodenum jejunum ileum Function - chemical digestion and absorption microvilli, villi and circular folds increase surface area

4. Small bowel surgery

5. Small intestine

6. Review of Anatomy and Physiology Large intestine - colon ileocecal valve to anus Cecum - first part of intestine - appendix Colon divided into 3 parts ascending transverse descending Function - eliminate undigestible food, absorb water, salt and vitamins

8. Large Intestine

9. Assessment of Bowel Function Subjective onset characteristics course severity precipitating factor relieving factors associated symptoms

10. Sample Interview Questions Can you describe the type of cramping and abdominal pain you are having? Have you every had bleeding from your rectum? Have you noticed any changes in your bowel habits?

11. Assessing the Abdomen Inspection, auscultation, percussion and palpation as described Rectal exam - polyps Stool for occult blood + requires further testing for colon CA or GI bleeding 2nd to peptic ulcers, ulcerative colitis or diverticulosis

12. Blood and Stool Melena - black tarry stool Blood on Stool - bleeding sigmoid colon, rectum Blood in Stool - colon, ulcerative colitis, diverticulitis, tumor, ulcer Stool black, hard = oral iron Strong odor = blood of high fat content steatorrhea

13. Nursing Care of Clients with Bowel Disorders Chapter 26

14. Disorders of Intestinal Motility Diarrhea serious in the young and elderly increase in the frequency, volume and fluid content of the stool Causes bacteria, or parasitic infections, malaborption, medications, diseases, allergies or pyschological

15. Diarrhea Clinical Manifestations vary widely from several large watery stool to very frequent small stools result in severe electrolyte imbalances hypokalemia - Low K+ hypomagnesemia - low Mg+ hypovolemia - fluid volume deficit - hypovolemic shock with vascular collapse

16. Diarrhea Collaborative Care treat underlying cause Labs stool specimen - for WBC’s, parasitic infections culture electrolytes - imbalance Diagnostic tests sigmoidoscopy - direct exam of bowel

17. Diarrhea Client prep consent, npo, enemas Dietary management fluid replacement - gatorade, pedialyte bowel rest for 24 hours - add milk last Pharmacology absorbents, anticholinergics, antibiotics

18. The Client with Constipation The infrequent or difficult passage of stool two or less BM’s per week affects elders - impaired health, medications, decrease physical activity Diagnostics Barium enema - tumors, diverticular disease colonoscopy - tumor, obstruction, take bx

19. Constipation Dietary Management high fiber - vegetable fiber adequate fluids Pharmacology laxatives for short term use bulk form agents for long term use enemas - acute short term or as prep

20. Irritable Bowel Syndrome Disorder characterized by alternating periods of constipation and diarrhea Cause - no organic cause found related to food ingestion, meds., stress, hormones looking at motor activity of the G.I. tract

21. IBS Clinical Manifestations Colic-like abdominal pain Altered bowel elimination mucous in stool, change in frequency, straining, urgency, incomplete emptying Bloating, tenderness Labs and Diagnostics stool specimen, colonoscopy, UGI with SBFT Dietary management add fiber - adds bulk and water content

22. Bloating and Cramping

23. The Client with Fecal Incontinence Loss of voluntary control of defecation Causes interfere with sensory or motor control of rectum and anal sphincters neuro -spinal cord injury, head injury local trauma - OB tears, anal-rectal injury, surgery Other - radiation, impaction, tumors, confusion

24. Fecal Incontinence Collaborative Care dx made by history digital exam - poor sphincter tone treatment bowel training program - establish regular pattern dietary changes stimulant - coffee, suppository, digital stimulation surgery - colostomy

26. Acute Inflammatory and Infectious Disorders Appendicitis inflammation of the appendix common cause of acute abd pain most common reason for emergency abd surgery most common in adolescents and young adults

27. Appendicitis Simple appendix is inflamed but intact Gangrenous tissue necrosis and microscopic perforations Perforated gross perforation and contamination of peritoneal cavity

28. Appendicitis Clinical Manifestations continuous mild generalized upper abd pain then intensifies and localizes to RLQ rebound tenderness - tenderness on release of pressure at McBurney’s point + Rt heel tap pain What about pain medications? nausea, anorexia, vomiting, low-grade fever perforation - increased pain, temp, abscess

29. Appendicitis Pathophysiology The appendix can become obstructed by fecalith (hard masses of feces) a stone, inflammation or parasites. As a result of the obstruction the appendix becomes distended with fluid. This increases pressure within the appendix and impairs its blood supply. The lack of blood supply leads to inflammation, edema, ulceration, and infection of the tissue. Can become necrotic and perforate if treatment is not indicated.

30. Appendicitis Interdisciplinary Care Labs - CBC, UA, pregnancy test Diagnostic studies - abd X-ray, pelvic exam, ABD ultrasound Pharmacology - IV’s , antibiotics - third generation cephalosporin - rocephin Surgery - Appendectomy - exploratory vs laproscopy

32. The Client with Peritonitis Inflammation of the peritoneum - is the most significant complication of acute abdominal disorders perforation of appendix, diverticulum, peptic ulcer, pancreatitis or GSW bacterial infection - E coli or klebsiella

33. Peritonitis Clinical Manifestations Abdominal Effects Diffuse or localized pain - rebound Boardlike rigidity diminished or absent bs distention, anorexia, nausea, vomiting Systemic effects fever, malaise, tachycardia, restlessness shock

35. Peritonitis Labs and Diagnostics CBC - WBC’s with shift to the left, immature wbc out to help fight infection Blood culture - bacterial invasion into blood stream Paracentesis - obtain peritoneal fluid Abd x-ray - free air under diaphragm indicative of gastrointestinal perforation

36. Peritonitis - Interdisciplinary Care Pharmacology broad-spectrum antibiotics until culture report obtained narcotic analgesic, antipyretics Surgery - laparotomy peritoneal lavage washing out cavity with copious amounts of isotonic soln drains - JP or pen rose, may be left open

37. Nursing Care - Peritonitis NGT intestinal decompression Pain - abd distention and inflammation assess - location, severity and type - analgesics fowler’s - minimize stress on abd structures alternative pain management - visualization, medication, relaxation

38. Nursing Care - Peritonitis Fluid volume deficit I & O, vs, wt., assess for dehydration Altered protection monitor for sign of infection, handwashing, aseptic technique for drsg changes Anxiety potential threat to life

39. The Client with Viral or Bacterial Infection Gastroenteritis describes general GI inflammation syndrome - diarrhea, vomiting, anorexia, nausea and pain organisms - Staphlococcal, Salmonella,Shigella, Botulism - life threatening, Cholera - third world countries dx - stool culture, tx - antibiotics, rehydration

40. Ulcerative Colitis chronic inflammatory bowel disorder of the mucosa and sub mucosa . Affects young 15-40 yrs old Cause unknown, genetic component, autoimmune, dietary factors - fiber poor foods, smoking Affects the large bowel

41. Ulcerative Colitis Clinical Manifestations insidious onset - attack last 1 to 3 months diarrhea - 30 to 40 stools per day with blood and mucus fatigue, anorexia, generalized weakness toxic megacolon - transverse colon is paralyzed may rupture, massive hemorrhage - need colostomy

44. Ulcerative Colitis Interdisciplinary Care supportive treatment Dx - by sigmoidoscopy, edema, inflammation, mucus and pus Pharmacology Azulfidine - sulfonamide antibiotic, acts topically on colonic mucosa to inhibit inflammatory process Dietary - npo with TPN, then low residue

45. Ulcerative Colitis Surgery not initial treatment ileostomy Nursing Care relieving abd cramping emotional support teaching about illness and special needs Nsg dx. - diarrhea and body image disturbance

47. The Client with Crohn’s Disease Slowly progressive, relapsing inflammatory disorder of GI tract diarrhea less severe, no blood or mucus RLQ pain, fever, malaise, fatigue affect young people 10-30 can occur anywhere in the GI tract, patchy lesions

48. Crohn’s Disease Interdisciplinary Care therapy is directed toward managing the symptoms and controlling the disease process Labs and Diagnostics Stool specimen X-ray - UGI with SBFT - shows ulcerations, strictures and fistulas colonosocpy - bx

49. Crohn’s - Interdisciplinary Care Pharmacology same as ulcerative colitis - anti inflammatory antidiarrheal - no risk of mega colon Dietary NPO - TPN, eliminate milk Surgery 2nd to complications, bowel obstruction - bowel resection

52. Malabsorption Syndromes A condition in which nutrients, carbohydrates, protein, fats, water, electrolytes, minerals, and vitamins are ineffectively absorbed by the intestional mucosa mostly disease of small intestine surgery of small intestine

53. Malabsorption Syndrome Clinical manifestations anorexia, abd bloating, diarrhea, weight loss, weakness, malaise, muscle cramps, anemia signs of malnutrition Celiac Disease hypersensitivity to gluten, protein found in cereal Tx - gluten free diet

54. Malabsorption Syndrome Lactose Intolerance deficiency of lactase the enzymes needed for digestion and absorbtion of lactose the primary carbohydrate in milk affects 90% of Asians, 75% of African Americans, high incidence among Jewish and Hispanic populations usually hereditary, symptoms occur in adolescence or early adulthood

55. Malabsorption Syndrome Short Bowel Syndrome from resection of significant portions of the small intestine CA, mesenteric thrombosis with bowel infarction, Crohn’s disease or trauma Treatment frequent small, high caloric and high protein meals multivitamin and mineral supplements

56. Neoplastic Disorders Polyps is a mass of tissue that arises from the bowel wall and protrudes into the lumen occur most often in the sigmoid colon and rectum 30% of people over age 50 have polyps most are benign, some have potential to become malignant - are removed

57. Polyps Interdisciplinary Care Diagnosis made by barium enema and sigmoidoscopy or colonoscopy Follow-up recommended because polyps tend to recur Consider a “silent” disease - few or no symptoms with significant risk of CA

58. The Client with Colorectal Cancer Malignant tumor arising from the epithelial tissues of the colon or rectum 2nd leading cause of cancer death in Western countries long term survival rate is only 35% occurs more in males than females occurs after age 50

59. Colorectal Cancer Risk Factors over age 50 polyps in colon or rectum cancer elsewhere in the body family history ulcerative colitis or crohn’s disease radiation, immunodeficiency disease dietary - high fat, high caloric, low Ca+ and fiber

60. Colorectal Cancer Clinical Manifestations no symptoms until it becomes advanced slow growth pattern - 5-10yrs. for symptoms to develop bleeding change in bowel habit - diarrhea or constipation pain, anorexia, weight loss - advance disease

61. Colon Cancer

62. Colorectal Cancer Interdisciplinary Care establish dx - colonoscopy surgical intervention adjuncts of chemotherapy and radiation

63. Colorectal Cancer Surgical resection of tumor, adjacent colon and regional lymph nodes Dukes Staging Stage A - confined to bowel wall Stage B - penetration of bowel wall Stage C - lymph node involvement Stage D - distant metastases

64.  Permanent for tumors of rectum or sigmoid colon Hartmann pouch – temporary the distal portion of the colon is left in place and sewn shut

65. Double Barrel colostomy

66. Nursing Care of the Client Having Bowel Surgery Pre-operative consent assess level of understanding bowel prep oral and parental antibiotics cathartics and enema to reduce risk of bowel contamination

67. Nursing Care of the Client Having Bowel Surgery Post-operative Nursing Care Routine post-op care vital signs, turn, cough, deep breath q2hrs I & O - NGT drainage, surgical drains assess for post-op hemorrhage Assess for bowel sounds and distention Provide pain relief Assess resp. status - teach to splint

68. Nursing Care of the Client Having Bowel Surgery Post-operative care Assess position and patency of NGT Assess stoma - color, size, check pallor Assess stoma out-put - usually bright red initially then changing to clear greenish yellow by day 2-3 Encourage ambulation, this stimulates peristalsis teach colostomy care

69. Nursing Care of Clients Having Bowel Surgery Effects of ostomy on Body Image adjust to loss of body organ and dx of cancer show acceptance of client and ostomy concerned over the affect of cancer develop a trusting relationship listen actively ostomy, cancer support groups, social services

70. Colostomy Surgery

71. Case Study - Colorectal Cancer W.C., 65yr old male, retired railroad employee, husband and father of 3 grown children. Has 3 month history of small amount of blood and mucus in stool. Has a sensation of rectal pressure and has notice his stool has changed in diameter, now is pencil thin.

72. Physician palpates a tumor in the rectum. Colonoscopy and bx confirm adenocarcinoma W.C. is scheduled for a abdonminalperitoneal resection and sigmoid colostomy

73. His wife has many questions and asks, why does the colostomy have to be permanent? Why does he need erythromycin and neomycin tablets? She then asks, is he going to be ok?

75. Physician Orders Explain the rationale behind these orders Insert NGT and connect to low intermintent suction Insert foley catheter Routine post-op v.s., OOB tonight See PCA order sheet (M.S. 1mg q 10min, up to 10mg every 4 hours) NPO

76. Nursing Interventions Explain the rationale behind these interventions establishing a therapeutic relationship assessing patency and position of the NGT assessing respiratory status assessing b.s. assess stoma and stoma output teaching to splinting the incision

77. Structural and Obstructive Disorders Hernia protrusion of an organ or structure through a defect in the muscular wall Inguinal hernias 75% of all hernias cause by improper closure of the tract that develops as the testes descend into the scrotum before birth bulge at inguinal cannal reducible - contents of the sac return to abd cavity strangulated hernia - blood supply is compromised

78. Structural and Obstructive Disorders Umbilical hernias occur more frequently in women obesity, mult. pregnancies, prolonged labor tend to enlarge steadily strangulation is common Incisional or Ventral hernias occur at previous surgical incision

80. The Client with an Intestinal Obstruction Occurs when intestinal contents fail to be propelled through the lumen of the bowel Small intestine obstruction ileum of small intestine most common site Mechanical Obstruction physical barrier, tumor or scar tissue Functional Obstruction - paralytic ileus peristalsis fails

81. Bowel Obstruction

82. The Client with an Intestinal Obstruction Clinical Manifestations cramping, colicky abdominal pain, can be intermittent or increase in intensity vomiting high-pitched tinkling bowel sounds - reflects the bowels attempt to propel contents past the obstruction later stages - absent bowel sounds electrolyte imbalance - hypovolemia - shock

83. The Client with an Intestinal Obstruction Large Bowel Obstruction usually occurs in sigmoid colon cancer most common cause Clinical Manifestations abdominal pain and constipation abdomen is distended and tender to palpation Treatment for Bowel Obstructions NGT - functional surgery - mechanical

84. Diverticulitis

85. The Client with Diverticular Disease Diverticula acquired saclike projections of mucosa through the muscular layer of the colon 90-95% occur in the sigmoid colon increased incidence in US, Australia, United Kingdom and France related to cultural factors - diet high in refined foods and low in fiber

86. The Client with Diverticular Disease Diverticulosis the presence of diverticula 80% are asymptomatic Clinical Manifestations left-sided abd pain, constipation and diarrhea narrow stools, occult bleeding

87. The Client with Diverticular Disease Diverticulitis inflammation and microscopic perforation of diverticular mucosa undigested food becomes trapped, blood flow is impaired - leads to abscess or peritonitis Interdisciplinary Care Chronic diverticular disease - dietary changes Acute diverticulosis - bowel rest, antibiotics, eventually surgery

89. Anorectal Disorders The Client with Hemorrhoids hemorrhoidial veins become weak, distended, develop varices - cause is straining, pregnancy also increases intra-abdominal pressure internal or external bleeding, bright red, unmixed with stool pain associated with thrombosed or ulcerated

90. The Client with Hemorrhoids Interdisciplinary Care conservative therapy - diet, increase fiber, fluids, bulk forming laxative, Preparation H surgery sclerotherapy - inject chemical irritant to induce inflammation - fibrosis - scarring rubber band ligation - rubber band placed snugly around - necrosis - slough cryosurgery - necrosed by freezing with probe

91. The Client with Hemorrhoids Nursing Care - post-op inspect rectal dressing for bleeding pain management - position of comfort - side lying ice pack over rectal drsg sitz bath tid and prn bowel movement meds - analgesics, stool softeners

92. The Client with Anorectal Lesions Anal Fissure ulcers of the epithelium of the internal sphincter Anorectal Abscess bacteria invades pararectal space - I & D Anorectal Fistula tunnel or tubelike tract - leaks stool Pilonidal Disease - chronic draining sinus