Care of Patients with Noninflammatory Intestinal D/O Chapter 59 Care of Patients with Noninflammatory Intestinal D/O Spastic contractions of the colon as they occur with irritable bowel syndrome.

Lower GI Bleed Common causes of lower GI bleeding.

Colorectal Cancer The incidence of cancer in relation to colorectal anatomy.

Colorectal Cancer (cont’d) Colorectal – refers to colon and rectum, which together make up large intestine Most CRCs are adenocarcinomas Etiology: Age >50 yr Genetic predisposition Personal/family history of cancer Familial adenomatous polyposis

Staging 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, up to 4 regional lymph nodes Stage IV—any level of tumor invasion; many lymph nodes affected with distant metastasis

Colostomies Different locations of colostomies in the colon.

Colostomy Care Normal appearance of stoma Signs and symptoms of complications Measurement of stoma Choice, use, care, application of appropriate appliance to cover stoma Measures to protect skin Dietary measures to control gas and odor Resumption of normal activities

Mechanical Obstruction Two types of mechanical obstruction.

Common Abdominal Hernias Types of abdominal hernias.

Polyps Pedunculated and sessile polyps. Pedunculated polyps, such as tubular adenomas, are stalk-like. Sessile polyps, such as villous adenomas, are broad based.

The patient is a 57-year-old male with a family history (sister, father) of colorectal cancer (CRC). His diet includes lots of red meat and fried foods. He was diagnosed with ulcerative colitis 3 years ago and treated for prostate cancer 2 years ago. What risk factors suggest a diagnosis of colorectal cancer for this patient? Positive family history with first-degree relatives; dietary habits (red meat and fried foods); history of ulcerative colitis and prostate cancer.

(cont’d) At the oncologist’s office, the patient tells the nurse that he has been experiencing vomiting and diarrhea. He states that he is tired all the time and has lost about 15 pounds over the past month. What diagnostic test would take priority at this time? Stool for fecal occult blood Serum electrolytes Colonoscopy EGD ANS: A The most common signs of colorectal cancer are rectal bleeding and anemia.

(cont’d) The patient’s stool is positive for occult blood and he is admitted to the inpatient oncology unit 3 hours later. Two hours after admission, the patient is passing bright red blood from his rectum. Which location does this suggest for the patient’s tumor? Transverse colon Descending colon Ascending colon Rectosigmoid colon ANS: D Tumors of the rectosigmoid colon are associated with hematochezia (the passing of red blood via the rectum). This tumor location is also associated with straining to pass stools and narrowing of stools. Additionally, the patient may report dull pain.

(cont’d) The next morning the patient is scheduled for surgery to remove the tumor and place a sigmoid colostomy. He returns to the unit with a clear ostomy pouch system in place. The stoma appears healthy. How would the nurse document this finding? How soon postoperatively would the nurse expect the colostomy to begin functioning? “Reddish pink, moist, and protrudes about 2 cm from the abdominal wall.” Initially the stoma may be slightly edematous and there may a small amount of bleeding. About 2 to 4 days postoperatively.

(cont’d) Three days later the stoma is functioning. What assessment of stool would the nurse expect? Very little stool and mostly gas Diarrhea liquid stool Pasty stool More solid stool ANS: D Immediate-postoperative stool may be liquid, but it becomes more solid depending on the location of the colostomy. Stool from an ascending colon colostomy will be more liquid, stool from a transverse colon colostomy will be more pasty, and stool from a descending or sigmoid colostomy is more solid and similar to the usual stool expelled from the rectum.

(cont’d) The patient is discharged and home health services are arranged. What are the home health nurse’s assessment priorities? (Select all that apply.) Gastrointestinal status Condition of the stoma Peristomal skin condition Patient and family’s coping skills Results of daily laxative prescription ANS: A, B, C, D The home health nurse’s priorities are related to the patient’s stoma care, GI status, and psychosocial status of the patient and family as a result of the surgery. Patients with a colostomy are often prescribed a stool softener, but usually not prescribed a laxative.

Audience Response System Questions Chapter 59 Audience Response System Questions 17

Question 1 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 2 True or False: Emotional stress is a risk factor for irritable bowel syndrome (IBS). True False Answer: B (False) Rationale: Emotional stress does not cause IBS, but people with IBS may have their bowels react more to stress. So, if a patient already has IBS, stress can make the symptoms worse. Learning to reduce stress can help with IBS. With less stress, patients may have less cramping, pain, and better symptom relief. (Source: Accessed August 13, 2011, from http://digestive.niddk.nih.gov/ddiseases/pubs/ibs_ez/)

Question 3 Which ethnic group has a higher incidence of colorectal cancer? Hispanic/Latino Asian Caucasian African-American Answer: D Rationale: African-American men and women are diagnosed with and die from colorectal cancer at higher rates than men and women of any other United States racial or ethnic group. The reason for this is not yet understood. (Source: Accessed August 13, 2011, from http://www.cancer.org/Cancer/ColonandRectumCancer/MoreInformation/five-myths-about-colorectal-cancer; and http://www.cdc.gov/vitalsigns/CancerScreening/)