Adult medical surgical nursing
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Adult Medical Surgical Nursing. Gastro-intestinal Module: Conditions of Malabsorption Inflammatory Bowel Disorder: Crohn’s Disease; Ulcerative Colitis. Conditions of Malabsorption. Malabsorption is the inability of the intestinal mucosa to absorb one or more of the major nutrients.

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Adult Medical Surgical Nursing

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Adult medical surgical nursing

Adult Medical Surgical Nursing

Gastro-intestinal Module:

Conditions of Malabsorption

Inflammatory Bowel Disorder: Crohn’s Disease; Ulcerative Colitis


Conditions of malabsorption

Conditions of Malabsorption

  • Malabsorption is the inability of the intestinal mucosa to absorb one or more of the major nutrients


Conditions of malabsorption1

Conditions of Malabsorption

  • Infection: gastro-enteritis, amoeba, giardia

  • Post-intestinal surgery (resection)

  • Specific nutrient disorders: lactose intolerance, cystic fibrosis, coeliac

  • Maldigestion of fats (also fat-soluble vitamins ADEK): related to obstruction of bile flow into the intestine

  • Inflammatory bowel disorder: Crohn’s Disease and Ulcerative Colitis


Conditions of malabsorption clinical manifestations

Conditions of Malabsorption: Clinical Manifestations

  • Diarrhoea, watery or with blood, mucus and/ or pus

  • Frequent loose bulky offensive stools

  • Pale, grey fatty stools

  • Abdominal distension/ flatulence

  • Weakness, muscle-wasting, weight loss

  • Malnutrition and loss of well-being, dehydration

  • Vitamin deficiency, anaemia, bruising tendency, osteoporosis, osteomalacia


Conditions of malabsorption diagnostic tests

Conditions of Malabsorption: Diagnostic Tests

  • History and physical examination

  • Blood: CBC, ESR, CRP, Urea, Electrolytes, LFTs, Plasma proteins

  • Stool: analysis, culture, parasites, 24-hour fat content, Guaic occult blood

  • Endoscopy

  • Colonoscopy

  • Barium or Gastrografin studies


Inflammatory bowel disorder

Inflammatory Bowel Disorder

  • A chronic inflammatory condition which may relate to auto-immune disorder

  • There are two major conditions:

  • Crohn’s Disease (regional enteritis)

  • Ulcerative Colitis

  • Both conditions hold a risk for development of colon cancer


Adult medical surgical nursing

Crohn’s Disease


Crohn s disease pathophysiology

Crohn’s Disease: Pathophysiology

  • Sub-acute/ chronic inflammation of the distal ileum and ascending colon mainly

  • Mucosal ulceration in patches, separated by normal tissue

  • Ulceration may extend through all layers

  • Can cause perforation to the peritoneum

  • Inflammatory process leads to fibrosis, thickening the bowel wall and narrowing the lumen


Crohn s disease clinical manifestations

Crohn’s Disease:Clinical Manifestations

  • Abdominal mild colicky pain (cramps from semi-obstruction)

  • Chronic diarrhoea (containing blood, mucus, pus): oedematous inflamed intestine with weeping irritating discharge

  • Weight loss, malnutrition, anaemia (chronic malabsorption), emaciation, dehydration

  • Fever and pain if abscesses

  • Acute severe pain/ shock if perforation

  • Remission and exacerbation


Crohn s disease diagnosis

Crohn’s Disease: Diagnosis

  • Blood:

  • ↑ WCC, ESR, CRP (inflammation)

  • ↓ Hb, ↓ plasma proteins (albumen)

  • Electrolyte imbalance

  • Stool: blood, mucus, pus

  • Endoscopy/ colonoscopy: typical ulcerated patches seen

  • Barium or gastrografin studies: “string” sign, stricture/narrowing of intestinal lumen


Adult medical surgical nursing

Ulcerative Colitis


Ulcerative colitis pathophysiology

Ulcerative Colitis: Pathophysiology

  • Chronic inflammatory disease of the mucosa of the colon and rectum (10-15% will develop colon cancer)

  • Ulceration, desquamation and shedding of mucosa, bleeding, pus (severe protein loss)

  • Begins in rectum. May affect whole colon

  • Recurrent lesions, one after the other

  • Strictures and muscular hypertrophy


Ulcerative colitis clinical manifestations

Ulcerative Colitis:Clinical Manifestations

  • Abdominal cramp-like pain (rebound tenderness right lower quadrant)

  • Diarrhoea (10-20 liquid stools daily with blood, mucus and pus in stool)

  • Rectal bleeding and urge to defaecate

  • Anorexia, severe weight loss, emaciation, muscle wasting, malnutrition, dehydration, anaemia, hypocalcaemia

  • Erythema, uveitis, arthritis (auto-immune)


Ulcerative colitis diagnosis

Ulcerative Colitis: Diagnosis

  • Blood:

  • ↑ WCC, ESR, CRP (inflammation)

  • ↓ Hb, ↓ plasma proteins (serum albumen)

  • Electrolyte imbalance

  • Stool: frequent diarrhoea with pus, blood, mucus

  • Sigmoidoscopy: severe mucosal ulceration and shedding

  • Barium/ Gastrografin: shows shortening and dilatation of bowel (may perforate)


Adult medical surgical nursing

Inflammatory Bowel Disorder:

(Crohn’s Disease and Ulcerative Colitis)

Management


Inflammatory bowel disorder medical treatment

Inflammatory Bowel Disorder: Medical Treatment

  • Rest for the patient and for the bowel (to reduce inflammation and inappropriate immune response)

  • Nutrition and fluid replacement:

  • Encourage oral fluids

  • Intravenous infusion if electrolyte imbalance

  • Low-residue, high protein, high calorie diet as tolerated, with vitamin, minerals

  • Total Parenteral Nutrition (TPN)


Inflammatory bowel disorder medications

Inflammatory Bowel Disorder: Medications

  • Medications:

  • Sedatives and antispasmodics to control bowel motility and pain: Diazepam, Codeine Phosphate, Imodium, Buscopan

  • Antibiotics (Sulphonamides) to control secondary infection/ abscesses

  • Corticosteroids (oral and by enema): anti-inflammatory; immunomodulators if severe- lower immune response (Imuran)


Inflammatory bowel disorder surgery

Inflammatory Bowel Disorder: Surgery

  • Where conservative treatment fails or complications occur

  • Resection of the affected part of the intestine and ileostomy is performed above as a faecal diversion

  • May be temporary or permanent stoma*

  • May involve pouch of ileum (Kock pouch)

  • Contents of ileostomy drainage are fluid, contain proteolytic enzymes and are irritant to the skin (extreme care needed)


Post surgery complications

Post-Surgery Complications

  • Diarrhoea leading to dehydration and electrolyte imbalance: excessive fluid loss through stoma

  • Stomal stenosis/ retraction

  • Peri-stomal irritation/ excoriation (poorly-fitting pouch; proteolytic enzymes in fluid)

  • Psychological/ social implications

  • Renal calculi (dehydration)

  • Gall-stones (change in absorption of bile acids)


Inflammatory bowel disorder nursing considerations

Inflammatory Bowel Disorder:Nursing Considerations

  • Emotional support (patient is often depressed)

  • Teaching about fluids, diet, medications, rest

  • Monitoring progress, stool frequency, fluid balance, electrolytes, weight, skin turgor

  • Post-surgery stoma care: check that stoma is pink and moist, no stenosis

  • Skin care: anti-fungal powder or barrier cream

  • Accurate fitting (and avoid frequent changing) of stomahesive patches (proteolytic enzymes)


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