Lower GI Problems Module 1

1. Lower GI ProblemsModule 1

3. Diarrhea�Etiology and Pathophysiology Classified by Increased fluid secretion Bacterial invasion Laxatives Foods Hormonal changes/imbalances Tumor Decreased fluid absorption Malabsorption/maldigestion Mucosal damage Pancreatic insufficiency Intestinal enzyme deficiency Bile salt deficiency Decreased surface area Motility disturbances Irritable bowel syndrome (IBS) Diabetic enteropathy Gastrectomy Can be a combination of any of the above

4. Diarrhea�Etiology Virus Rotovirus Bacterial E. Coli Samonella, Shigella Clostridium difficile-can be caused by antibiotic use, give client Flagyl to treat If client takes Flagyl, remind client not to take ETOH or severe vomiting will occur Parasitic Giardia Crytosporidium

5. Diarrhea�Clinical Manifestations Acute Usually infection Tenesmus Explosive diarrhea Cramping Spasmotic contraction of anal sphincter May have fever, N/V Usually self-limiting

6. Diarrhea�Clinical Manifestations Chronic Persists for more than 2 weeks Can be life threatening i.e. dehydration, electrolyte imbalance

7. Diarrhea�Diagnostic Studies H&P History of travel Contacts Family history Chemistries K, BUN, Creat Stool specimens O&P WBC Parasites Fat content C.Diff Blood, mucous CBC WBC

8. Diarrhea�Treatment Replace fluids, electrolytes Decrease number, amount of stools Give antidiarrheals

9. Antidiarrheals�Demulcents Protects mucous membranes, promotes intestinal absorption of fluids and electrolytes Can create constipation Pepto Bismol (Bismuth subsalicylate) Can give 30ml q 30 min-1hr up to 8 doses/24hr Donnagel (drobromide),Kaopectate 60-120ml after each loose stool

10. Antidiarrheals�Anticholinergic Inhibits GI motility Can cause constipation Donnagel Lomotil (diphenoxylate with atropine) 2.5-5mg BID to QID Immodium (loperamide) 4mg initially, then 2mg after each loose stool Do not exceed 16 mg/day

11. Antidiarrheals�Antisecretory Can cause constipation Decreases intestinal secretion Increase absorption of fluids and electrolytes Sandostatin Not as commonly used as other antidiarrheal agents

12. Antidiarrheals�Narcotic Can cause constipation Inhibits GI peristalsis Paragoric 5-10ml 1-4 times/day Donnagel

13. Fecal Incontinence-Pathophysiology Involuntary passage of stool Fecal contents passes rectum causing distention Relaxation of internal sphincter, contraction of external sphincter Motor and sensory involved

14. Fecal Incontinence � Etiology Primary An impairment of either motor or sensory Traumatic Neurological Inflammatory Medications Mobility impairments Secondary Incontinence as a result of fecal impaction (accumulation of hard stool in rectum or sigmoid)

15. Fecal IncontinenceDiagnostic Studies H&P Rectal exam Flexible sigmoidoscopy Barium enema Colonoscopy Anorectal mamography Testing related to sensory or motor impairment

16. Fecal Incontinence-Nursing Care Skin care Bowel training program Offer bedpan/toileting at intervals Ducolax suppositories Digital stimulation ? Disimpaction ?? Perianal pouching

17. Constipation Decrease in frequency of bowel movements Hard, difficult to pass stools Decrease in stool volume Retention of feces in the rectum Factors Diet Exercise Client�s normal habits Fluid intake Medication intake Disease processes Depression/stress

18. Constipation�Etiology Colonic disorders i.e. Irritable Bowel syndrome, diverticulitis, intussusception Medications i.e. antidiarrheals, narcotics Systemic Disorders i.e. diabetes, pregnancy Collagen diseases Neurological disorders i.e. Hirschsprung�s, Multiple sclerosis, Parkinson�s

19. Constipation�Clinical Manifestations Abdominal distention Anorexia Hard, dry stool Headache Flatulence Nausea/Vomiting Straining Tenesmus

20. Pharmacological Intervention for Constipation Cathartic Agents Bulk Forming Stool softeners Saline and Osmotic solutions Stimulants Use cautious with abdominal pain/suspected obstructions/perforations/GI Bleeds Avoid overuse of agents-atonic colon can occur

21. Bulk Forming Agents Metamucil, Fiber Con Absorbs water, increase bulk Onset: within 24 hrs May decrease absorption of Coumadin, Digoxin Administer with a full glass of water, follow with additional fluids

22. Stool Softeners Colace, Pericolace Promotes water into stool Lubricates intestinal tract, softens feces Onset: up to 72 hr Administer on empty stomach with large amount of water, liquid for better results

23. Saline and Osmotic Solutions Milk of Magnesium, Fleets enema, Phosphosoda Retention of fluid in intestine Onset: 15 min-3 hr Magnesium preparation may be contraindicated in renal failure clients MOM may decrease absorption of quinolones

24. Stimulants Cascara, Ex-lax, Ducolax Increases peristalsis by irritating colon Onset: 12 hr

25. Constipation-Complications Valsalva-straining to pass stool, creating bradycardia, drop in BP Diverticulosis Fecal impaction Perforation Bleeding hemorrhoids

26. Constipation-Diagnostic studies H&P Abdominal x-rays Barium enema Sigmoidoscopy Colonoscopy

27. Constipation-Nursing care Nutrition Insoluable fiber-Remains unchanged until it reaches colon i.e. wheat, bran Soluable fiber-gel like substance, adds viscosity to undigested foods i.e. oat bran, fruits Increase fluids 3000ml/day Exercise Establish routine for elimination Avoid overuse of laxatives and enemas Do not delay defecation