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

Lower GI Bleed

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

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.

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-HT4 antagonists, M3-receptor antagonists, and tricyclic antidepressants Stress management based on the patient’s current and ongoing stressors Complementary and alternative therapies used to reduce symptoms and discomfort

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

Common Abdominal Hernias

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?

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

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

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.

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)

Colorectal Cancer (Cont’d)

Health Promotion and Maintenance Genetic testing for FAP (familial adenomatous polyposis)and HNPCC (herediary nonpolyposis colorectal cancer) Diet modification Colon cancer screening Aspirin therapy Dietary calcium supplements

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.

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

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

Nonsurgical Management (Cont’d) Radiation therapy Drug therapy

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

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

Colostomies

Surgical Management Operative procedures Postoperative care

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

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

Mechanical Obstruction

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

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

Assessment Laboratory assessment Imaging assessment Other diagnostic tests

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

Surgical Management Exploratory laparotomy Preoperative care Operative procedure Postoperative care

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 trauma caused by gunshot wounds, stabbing

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’s sign: pt on Left side and do percussion. Left flank dullness and resonance over the right flank Kehr’s sign: 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.

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

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

Polyps (Cont’d)

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

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

NCLEX TIME

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% Answer: B Rationale: Irritable bowel syndrome is the most common digestive disease seen in clinical practice and is estimated to occur in 10% to 22% of the U.S. population.

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 Answer: C Rationale: Intussusception is a telescoping of the intestine within itself. Singultus (hiccups) is common with all types of intestinal obstruction. The vagus and phrenic nerves stimulate the hiccup reflex. Intestinal obstruction can increase the intraabdominal pressure, causing pressure on the phrenic nerve and the symptom of singultus (hiccups).

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. Answer: B Rationale: Chronic diarrhea can present other complications related to skin irritation, erosion, and pressure ulcer development. Using medicated wipes that provide a protective barrier to repel moisture will protect the fragile perineal skin. Washcloths and tissue paper can further irritate the skin. It is also important to keep the skin clean and dry. Consult a nutritionist to add fiber to the diet to bulk up the stool, and review medications that can cause diarrhea. Source: Roach, N., & Christie, J. (2008). Fecal incontinence in the elderly (Chart 59-7). Geriatrics, 63(2), 13-22.

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 Answer: C Rationale: The most common symptoms of irritable bowel syndrome (IBS) include pain in the left lower quadrant of the abdomen, nausea, constipation, diarrhea, belching, and bloating. IBS is frequently triggered by stress and often associated with mental or behavioral illness. IBS can be misdiagnosed as other lower intestinal disorders.

Question 5 What percentage of people develop polyps or colorectal tumor by age 70 years? 10% 25% 40% 50% Answer: D Rationale: At least 50% of people in the United States and other Western populations develop either a colorectal tumor or benign polyp by the age of 70 years.