Chapter 59

1. Chapter 59 Care of Patients with Noninflammatory Intestinal Disorders Mrs. Kreisel MSN, RN NU130 Adult Health Summer 2011

2. Lower GI Bleed

3. Irritable Bowel Syndrome (IBS) • IBS is a functional GI disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. • Manning criteria are present: • Abdominal pain relieved by defecation or falling asleep • Abdominal pain associated with changes in stool frequency or consistency

4. Irritable Bowel Syndrome (Cont’d) • Abdominal distention • The sense of incomplete evacuation of stool • The presence of mucus with stool passage • A flare-up of symptoms usually brings the patient to the health care provider.

5. Treatment • Health teaching—teaching the patient to avoid problem stimulants • Diet therapy—eliminating offending or upsetting foods • Drug therapy—bulk-forming laxatives, antidiarrheal agents, 5-HT4antagonists, M3-receptor antagonists, and tricyclicantidepressants • Stress management based on the patient’s current and ongoing stressors • Complementary and alternative therapies used to reduce symptoms and discomfort

6. Herniation • Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes • Types of hernia include: • Indirect inguinal • Direct inguinal • Femoral • Umbilical • Incisional or ventral

7. Common Abdominal Hernias

8. Classification of Hernias • Reducible: When the contents of the hernial sac can be placed back into the abdominal cavity by pressure. • Irreducible: Also know as incarcerated hernia, cannot be reduced or placed back into the abdominal cavity. Requires emregency surgical evaluation. • Strangulated: When the blood supply to the herniated segment of the bowel is cut off by pressure from the hernial ring (the band of muscle around the hernia). • WHAT NURSING CONSIDERATIONS ARE IMPORTANT FOR THIS TYPE OF HERNIA?

9. Nonsurgical Management • Truss: For people not able to undergo surgery and is mainly for males. • It is a pad made with firm material and is held inplace over the hernia with a belt to keep the abdominal contents from protruding into the hernia sac. • The surgeon must reduce the hernia if it is not incarcerated. The patient applies it in the morning. • Lots of Nursing Education is the priority

10. Surgical Management • Preoperative care—NPO day of surgery • Operative procedures: • Minimally invasive inguinal hernia repair (MIIHR) (herniorrhaphy) • Hernioplasty • Open or conventional herniorrhaphy

11. Postoperative Care • After open surgical approach, have patient avoid coughing. • After indirect inguinal hernia repair, a scrotal support and use of ice bags to the scrotum may be used to prevent swelling. Elevation of the scrotum on a soft pillow helps prevent and control swelling. • Difficulty voiding.

12. Colorectal Cancer (CRC) • Colorectal refers to the colon and the rectum, which together make up the large intestine. • Most CRCs are adenocarcinomas. • Etiology: • Age older than 50 years • Genetic predisposition • Personal or family history of cancer • Familial (disease that occurs more in a family then would be expected by chance) adenomatous (glandular tissue over growths) polyposis (the presence of numerous polyps)

13. Colorectal Cancer (Cont’d)

14. Health Promotion and Maintenance • Genetic testing for FAP (familial adenomatouspolyposis)and HNPCC (herediarynonpolyposis colorectal cancer) • Diet modification • Colon cancer screening • Aspirin therapy • Dietary calcium supplements

15. Clinical Manifestations • Most common signs—rectal bleeding, anemia, and a change in the stool. • The clinical manifestations of colon rectal cancer depend on the location of the tumor.

16. Laboratory Assessment • Hemoglobin and hematocrit values usually decreased • Fecal occult blood test • Possible elevation of carcinoembryonic antigen • Imaging assessment • Other diagnostic tests • Genetic counseling

17. Nonsurgical Management • American Joint Committee on Cancer • Stage I—tumor invades up to muscle layer • Stage II—tumor invades up to other organs or perforates peritoneum • Stage III—any level of tumor invasion and up to 4 regional lymph nodes • Stage IV—any level of tumor invasion; many lymph nodes affected with distant metastasis

18. Nonsurgical Management (Cont’d) • Radiation therapy • Drug therapy

19. Surgical Management • Colon resection • Colectomy • Abdominoperineal (AP) resection • Colostomy • Minimally invasive surgery

20. Surgical Management (Cont’d) • Preoperative care includes: • Consultation with enterostomal therapist • Discussions with surgeon of risk for sexual and urinary dysfunctions • Bowel prep • Nasogastric tube and IV line placed for use after surgery • Assignment of case manager for long-term consequences

21. Colostomies

22. Surgical Management • Operative procedures • Postoperative care

23. Nursing Interventions: PRIMARY: Assess the meaning and effect of cancer as perceived by the client! Colostomy Care • Normal appearance of the stoma • Signs and symptoms of complications • Measurement of the stoma • Choice, use, care, and application of appropriate appliance to cover stoma • Measures to protect the skin • Dietary measures to control gas and odor • Resumption of normal activities

24. Intestinal Obstruction • Mechanical obstruction • Nonmechanical obstruction, also known as paralytic ileus or adynamic ileus • Strangulated obstruction resulting from tumors, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis, vascular disorder, and adhesions

25. Mechanical Obstruction

26. Clinical Manifestations of Mechanical Obstruction • Midabdominal pain or cramping • Vomiting • Obstipation (extreme constipation) • Diarrhea • Alteration in bowel pattern and stool • Abdominal distention • Absence of Borborygmi (a gurgling, splashing sound normally heard over the large intestine; caused by gas passing through the liquid contents of the intestine) • Abdominal tenderness

27. Clinical Manifestations of Nonmechanical Obstruction • Constant, diffuse discomfort • Abdominal distention • Decreased to absent bowel sounds • Vomiting • Obstipation

28. Assessment • Laboratory assessment • Imaging assessment • Other diagnostic tests

29. Nonsurgical Management • Nothing by mouth • Nasogastric tube placement • Nasointestinal tubes • IV fluid replacement and maintenance • Mouth care • Pain management • Drug therapy

30. Surgical Management • Exploratory laparotomy • Preoperative care • Operative procedure • Postoperative care

31. Abdominal Trauma • Injury to the structures located between the diaphragm and the pelvis, which occurs when the abdomen is subjected to blunt or penetrating forces • Organs may include the large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary bladder • Blunt abdominal trauma, which often occurs in motor vehicle accidents • Penetrating abdominal traumacaused by gunshot wounds, stabbing

32. Assessment • Assess airway, breathing, and circulation • Assess for: • Hypovolemic shock • Cullen’s sign: bluish discoloration of the periumbilical skin due to intraperitoneal hemorrhage. • Turner’s sign: : bluish discoloration on the flank may indicate retroperitoneal bleeding into the abdominal wall • Ballance’ssign: pt on Left side and do percussion. Left flank dullness and resonance over the right flank • Kehr’ssign: Left shoulder pain resulting from diaphragmatic irritation as seen in spleen injury. • Dullness over hollow organs like the stomach or intestines may mean blood or fluid in that area.

33. Abdominal Trauma: Emergency Care • Two large-bore IV lines are placed • Central venous catheter • Type and crossmatch 4 to 8 units of blood • Balanced saline solution, crystalloids, and possibly blood • Arterial blood gas assessment • Fluid and electrolyte management • Continuous hemodynamic monitoring • Surgical management

34. Polyps • Small growths in the intestinal tract that are covered with mucosa and are attached to the surface of the intestine • Various types • Familial adenomatous polyposis • Usually asymptomatic, but can cause gross rectal bleeding, intestinal obstruction, and intussusception • Nursing care

35. Polyps (Cont’d)

36. Hemorrhoids • Unnaturally swollen or distended veins in the anorectal region • Internal hemorrhoids • External hemorrhoids • Nonsurgical management • Surgical management—hemorrhoidectomy

37. Malabsorption Syndrome • Syndrome associated with a variety of disorders and intestinal surgical procedures • Primary clinical manifestations—diarrhea and steatorrhea • Interventions: • Dietary management • Surgical or nonsurgical management • Drug therapy

38. NCLEX TIME

39. Question 1 How many Americans are estimated to suffer from irritable bowel syndrome? • 7% to 12% • 10% to 22% • 25% to 33% • 35% to 40%

40. Question 2 What symptom does the nurse expect the patient with intussusception to exhibit? • Decrease in pulse • Extremely elevated body temperature • Singultus (hiccups) • Frequent bloody stools

41. Question 3 What is a priority nursing intervention in the care of a patient with chronic diarrhea? • Keep the skin clean and dry. • Use medicated wipes rather than washcloths to clean the perineal area. • Consult a nutritionist for suggested fibers to add to the diet. • Review the patient’s medications that may be exacerbating the diarrhea.

42. Question 4 A 21-year-old female college student presents to the clinic complaining of lower abdominal pain, constipation and diarrhea, and belching and bloating sensation. The most likely cause of her symptoms is: • Appendicitis • Diverticular disease • Irritable bowel syndrome • Mental health disorder

43. Question 5 What percentage of people develop polyps or colorectal tumor by age 70 years? • 10% • 25% • 40% • 50%