Presentation on theme: "Management of Patients With Intestinal and Rectal Disorders"— Presentation transcript:
1Management of Patients With Intestinal and Rectal Disorders
2Basic Anatomy of Intestines Small Intestine3 regions: duodenum, jejunum, ileumLarge IntestineCecum, appendix, colon, rectum, anal canalAppendix is attached to the cecum
3Basic Anatomy of Intestines Figure 25–1 Anatomy of the large intestine.
4Basic Anatomy of Intestines Figure 25–2 Structure of the rectum and anus.
5Basic Anatomy of Intestines Figure 25–3 The four quadrants of the abdomen.
6Basic Anatomy of Intestines Figure 25–4 Digital examination of the A, anus; and B, rectum.
7Basic Anatomy of Intestines Figure 25–4 Digital examination of the A, anus; and B, rectum.
8Bowel Elimination Feces moved by peristalsis Defecation reflex Sigmoid colon contractsAnal sphincter relaxesValsalva maneuver expels feces
9Topics to Consider for Health History of a Problem Bowel Onset of problemCharacteristics and courseSeverityPrecipitating and relieving factorsCrampingBleeding increased constipationRecent travel outside the U.S.Any changes in activities of daily livingDiarrheaConstipation
10Physical Assessment of Bowel Integrity and Function Auscultation of bowel soundsRectal examAnal examExam of stoolPalpation (do last)
11Altered Intestinal Function Abdominal AssessmentInguinal AssessmentPerianal AssessmentFecal Assessment
12ConstipationAbnormal infrequency or irregularity of defecation; any variation from normal habits may be a problem.Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise.Increased risk in older age.Perceived constipation: a subjective problem in which the person’s elimination pattern is not consistent with what he or she believes is normal.
13Manifestations Fewer than 3 BMs per week Abdominal distention Decreased appetiteHeadacheFatigueIndigestionA sensation of incomplete evacuationStraining at stoolElimination of small-volume, hard, dry stools
15Diagnostic Findings Pt Hx Physical examination Barium enema or sigmiodscopy (to id is it from spasm or narrowing of the bowel)Anorectal manometry ( to id malfunction of the sphincter)DefecographyPelvic floor MRI
16Bowel Disorder Medications LaxativesFibercon, Bran, Citrucel, MetamucilNursing ResponsibilitiesMix agent with at least 6 oz of water just prior to administeringDo not administer to clients with possible stool impaction or obstructionClient and Family TeachingClient should drink at least 6-8 glasses of fluid dailyAgents may be mixed with fruit juice, water or milkDo not take at bedtime
17Patient Learning Needs See Chart 38-1Normal variations of bowel patternsEstablishment of normal patternDietary fiber and fluid intakeResponding to the urge to defecateExercise and activityLaxative use (see Table 38-1)
18DiarrheaIncreased frequency of bowel movements (more than 3 per day), increase amount of stool (more than 200 g per day), and altered consistency (i.e., looseness) of stool.Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors.May be acute or chronic.Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes.
19Manifestations Increased frequency and fluid content of stools Abdominal crampsDistentionBorborygmusPainful spasmodic contractions of the anusTenesmus
20Bowel Disorder Medications Antidiarrheal MedicationsKaopectate, Donnagel, Pepto-BismolNursing ResponsibilitiesAdminister on empty stomachAssess for potential contraindicationsClient and Family TeachingDo not use for more than one week unless specifiedTake in the morning
21Complications Fluid and electrolyte imbalances Dehydration Cardiac dysrhythmias
22Patient Learning Needs Recognition of need for medical treatmentRestDiet and fluid intakeAvoid irritating foods—caffeine, carbonated beverages, very hot and cold foodsPerianal skin careMedicationsMay need to avoid milk, fat, whole grains, fresh fruit, and vegetablesLactose intolerance (see Chart 38-2)
23Selected Diets Diarrhea Constipation Oral fluids, glucose electrolyte balanced (Gatorade, Pedialyte) for bowel restSoft foods after 24 hoursAdd milk products and fat lastConstipationHigh fiber (vegetable, raw fruits) to bulk up the stool massReduce intake of refined foods and meats
24Inflammatory Bowel Syndrome (IBS) Functional disorders of intestinal motilityNo known cause, usually hereditary factor, psychological stress, depression and anxiety, diet high in fat and stimulating or irritating food, alcohol consumption and smoking.More common in women than in menIn it the peristaltic waves are affected at specific segments & the intensity of propel the fecal pattern, no evidence of inflammation or tissue changes in intestinal mucosa
25C\M: Alteration in bowel pattern (primary symptoms) constipation or diarrhea or mixing of both, abdominal pain ( ↑ with eating & ↓ with defecation) , bloating, abd distensionDiagnosis: Stool studies, contrast X-ray, Barium enema, colonoscopy, proctoscopy, manometry, electromyographyMedical management: Restrict food and then reintroduction of foods is important to determine type of food that is irritating (beans, caffeinated products, fried food, alcohol, spicy food)Stress reduction techniquesManage diarrhea and constipation
26Nursing management: Nurse should educate family and patient about the importance of good dietary habits, chewing food slowly and eat regularly, not taking fluid with meal since it may cause abd destination, discouraged alcohol and smoking.
27Selected Diets IBS Gluten Free Diet: prescribed for clients with sprue May benefit from high fiber dietAdding bran and fluid reduces incidence of loose diarrheal stools and constipated stoolsGluten Free Diet: prescribed for clients with sprueLow Residue Diet: for clients with ileostomies and colostomies to prevent blockage.
28Diarrhea, Constipation, IBS, and Fecal Incontinence Loss of voluntary control of defecationContributing factors included both physiologic and psychologicDiagnosis based on client history and physical examination of the pelvic floor and anus to evaluate muscle toneNursing care includes bowel training programs and other measures to manage fecal incontinence
29Appendicitis:- Appendix is a small, finger-like structure within the abd, about 10 cm long and attached to the cecum just below the ileocecal valvefills with food and empties into the cecumIt is prone to obstruction and to infection (appendicitis)Common cause of acute abd, and emergency abdominal surgeryOccur in all ages but it common between age years
30Bowel DisordersFigure 26–1 A, McBurney’s point, located midway between the umbilicus and the anterior iliac crest in the right lower quadrant. It is the usual site for localized pain and rebound tenderness due to appendicitis. B, In an appendectomy, the appendix and cecum are brought through the incision to the surface of the abdomen. The base of the appendix is clamped and ligated; the appendix is then removed.
32C\M:vague epigastric pain or periumblical pain that progress to the RLQassociated with low grade fever, N & Vloss of appetiteLocalized tenderness at the Mc Burney’s point ( point between the umbilicus and the anterior superior iliac spinepositive rebound tenderness & rovsing signIf it rupture pain become more diffuse, with the development of abdominal distentionConstipation may occur, so pt not given laxative
33Medical management:Immediate surgery (Appendectomy)AB pre opIf it perforated drainage is applied to the abscess, then appendectomy is performedNursing management:Relive painPrevent FVDReduce anxietyPrepare the pt for surgeryAfter surgery place pt in high fowler position or supine with leg slightly flexed
34Give pt opioid analgesic Give food as toleratedTeach pt wound careInstruct pt that he can resume normal physical activity within 2-4wk’Nursing interventions for patient with complications after appendectomy:Peritonitis: observe for abd tenderness, fever, vomiting, abd rigidity and tachycardia, employ constant NG tube, correct dehydration, administer antibioticPelvic abscess: evaluate N & V, chills, fever, diaphoresis, diarrhea, prepare patient for rectal exam and surgical drainage,Subphrenic abscess (under the diaphragm): evaluate for chills and fever, prepare x-ray exam, prepare patient for surgical drainage of abscess.ileus: assess for bowel sounds, employ NG tube and suction, replace F& E, prepare for surgery
35Peritonitis:An inflammation of the peritoneum, the serous membrane lining the abd cavity and covering the viscera.Results from bacteria (E.Coli, klebsiella, Proteus& pseudomonas) or MO from GI disease, in women it occur from disease of reproductive organ. It can result from trauma or injury (gunshot, stab wound) or kidney inflammation.Other common causes are: appendicitis, perforated ulcer, diverticulitis and bowel perforation, peritoneal dialysis
36C\M:Diffuse pain (constant, localized, more intense near the site of inflammation)Tenderness and distention in the affected areaRebound tenderness & paralytic ileusN&V, increase temp ( ), increase pulse rateDiminished peristaltic movementRigid abdominal muscle- Pain diminished in pt with diabetes (advanced neuropathy, liver cirrhosis and on analgesic or corticosteroids
39Bowel DisordersFigure 26–13 Selected causes of mechanical obstruction. A, Adhesions; B, incarcerated hernia; C, tumor; D, intussusception; and E, volvulus.
40ColostomyIs the surgical creation of an opening into the colon , allows the drainage of colon content to the out side the body. It could be temporary or permanent fecal diversion.The consistency of the drainage is related to the placement of the colostomy.Indications : Large bowel obstruction, Colorectal cancer. The colostomy begins to function 3- 6 days after surgery.
41IleostomyIleostomy: the surgical creation of an opening into the ileum or small intestine, is commonly performed after a total colectomy. It allows for drainage of fecal matter from ileum to the out side of the bodyThe drainage is liquid to unformed and occurs at frequent intervals.Indication: chronic inflammatory bowel disease.
42Colorectal CancerThe third most common cause of cancer deaths in the United States.Risk factors (see Chart 38-8).Importance of screening procedures.Manifestations may include change in bowel habits; blood in stool—occult, tarry, bleeding; tenesmus; symptoms of obstruction; pain, either abdominal or rectal, feeling of incomplete evacuation.Treatment depends upon the stage of the disease.
46Diseases of the Anorectum Includes: Anorectal abscess, Anal fistula, Anal fissure, hemorrhoids, pilonidal sinus or cysts.Anal fissure:Is a longitudinal tear or ulceration in the lining of the anal canalCauses: trauma, persistent tightening of the anal canal from stress and anxiety (constipation), childbirth, overuse of laxativeC\M: painful defecation, burning and bleeding during defecation, bright red on the paper toiletRx: dietary modification ( fiber supplement), stool softener, increase water intake, sitz bath, suppositories with analgesic, surgery ( lateral internal shpinctretomy with fissure excision)
47Hemorrhoids Dilated veins in the anal canal 50 % of people above 50y of age develop hemorrhoids.Shearing effect on the anal mucosa during defecation leading to sliding of the anal structure ( hemorrhoidal and vascular tissue)Pregnancy may initiate it due to the pressure in the hemorrhoidal tissueClassifies as: internal or externalS&S: pain, itching, bright red bleeding with defecationExternal: associated with sever pain from inflammation and edema caused by thrombosis lead to ischemia and necrosis.Internal is not painful until they bleed or prolapsed when they enlarge
52Management:avoid strain, hygiene, high-fiber diet, fruit, bran and fluid intake.Analgesic, bulk-forming agents such as (Metamucil),, warm compresses, sitz bath, bed rest allow the engorgement to subside.None surgical treatment: infrared photocoagulation, bipolar diathermy, laser therapy (to affix the mucosa to underling muscle) .Surgical treatment: rubber-band Ligation procedure after anoscope. Can be painful and may cause secondary hemorrhage or infection.Cryosurgical hemorrhoidectomy: freezing the hemorrhoid for sufficient time to cause necrosis, painless, foul smelling, prolonged healing, not very common.For hemorrhoids with thrombosed vein hemorrhoidectomy is performed, after surgery small tube inserted through the sphincter to permit flatus and blood drainage
53Nursing Process: The Care of the Patient with an Anorectal Condition—Assessment Health historyPruritis, pain, or burningElimination patternsDietExercise and activityOccupationInspection of the area
54Nursing Process: The Care of the Patient with an Anorectal Condition—Diagnoses ConstipationAnxietyAcute painUrinary retentionRisk for ineffective therapeutic regimen management
56Nursing Process: The Care of the Patient with an Anorectal Condition—Planning Major goals may include adequate elimination patterns, reduction of anxiety, pain relief, promotion of urinary elimination, management of the therapeutic regimen, and absence of complications.
57Interventions Encourage intake of at least 2 L water a day Recommend high-fiber foodsBulk laxatives, stool softeners, and topical medicationsPromote urinary eliminationHygiene and sitz bathsMonitor for complicationsTeach self-care