1. Medical-Surgical Nursing
3rd edition
Chapter 29
Care of Patients with Disorders of the Lower Gastrointestinal System
Copyright © 2017, Elsevier Inc. All rights reserved.

2. Theory Objectives
Discuss the characteristics of irritable bowel syndrome.
Explain how diverticulitis occurs.
Identify the etiology and signs and symptoms of a strangulated hernia.
Illustrate how the two types of intestinal obstruction occur and the symptoms.
Describe the pathophysiology, methods of diagnosis, and treatment for ulcerative colitis and Crohn’s disease.

3. Theory Objectives (cont.)
Differentiate the signs and symptoms of appendicitis from those of peritonitis.
Plan nursing interventions for the patient having surgery of the lower intestine and rectum.
Discuss ways to help the patient psychologically adjust to having an ostomy.
Compare the characteristics of hemorrhoids, pilonidal sinus, and anorectal fistula.

4. Clinical Practice Objectives
Choose nursing interventions for the patient with inflammatory bowel disease.
Assess for the signs and symptoms of appendicitis.
Identify types of patients who are at risk for peritonitis.
Create a teaching plan for the prevention of colorectal cancer.

5. Irritable Bowel Syndrome
Etiology-function disorder of the GI motility
Pathophysiology –unknown…thought to result from hypersensitivity of the bowel wall that leads to disruption of intestinal muscles.
Signs and symptoms
Alteration in bowel elimination (either constipation or diarrhea or both)
Abdominal pain and bloating
Absence of detectable organic disease

6. Diagnosis of Irritable Bowel Syndrome
Diagnostic criteria include –no diagnostic testing recommended unless family hx etc.
Abdominal pain or discomfort characterized by
Relieved by defecation
Associated with a change in stool frequency or consistency
Other symptoms
Mucorrhea (mucus in the stool)
Abdominal bloating
Absence of organic disease

7. IBS

8. Treatment and Nursing Management of Irritable Bowel Syndrome
General health assessment
Bulk-forming agents, antidiarrheals (Lomotil), antispasmodics (Levsin), antidepressants, anticholinergics/sedatives, and mild analgesics to relieve discomfort
High-fiber diet
Patient teaching and reassurance
Complementary and alternative therapies

9. Diverticula page 671
Diverticulum - small blind pouch from a protrusion of mucous membranes of a hollow organ through weakened areas of a musculature wall
Etiology – diverticula primarily in the colon is inflamed or infected, accumulation of food particles
Pathophysiology – herniation of esophageal mucosa and submucosa into surrounding tissue

10. Diverticulosis
Signs, symptoms, and diagnosis – may have no symptoms depending on where the diverticula is: colon, intestine, bowel, esophagus
Bowel- constipation/ rectal bleeding
Intestine – diarrhea or constipation, acute left lower abdominal pain, bloating, nausea and vomiting. There may also be an obstruction
Esophagus- dysphagia, regurgitation, nocturnal cough and halitosis

11. Diverticulosis
Treatment – high fiber diet, increased fluids and bulk laxatives. Antidiarrheal medications and mild pain medications
Nursing Management – clear liquids for 2 to 3 days with oral antibiotics if indicated by an infection.
Recurrent episodes of diverticulitis require surgical removal of the affected part of the colon.

13. Intestinal Obstruction pg 671
Sudden or gradual blockage of intestinal tract – prevents normal passage of GI contents through intestines
Etiology and pathophysiology – mechanical obstruction (tumors, adhesions, hernias, twisting of the bowels – volvulus) or nonmechanical – paralytic ileus (failure of forward movement of bowel contents)after surgery, infections.

14. Intestinal Obstruction (cont.)
Signs and symptoms depends of location of the obstruction (see page 672)
FECAL ODOR OR MATERIAL IN THE EMESIS SUGGESTS A COMPLETE INTESTINAL OBSTRUCTION
Diagnosis and treatment
Diagnostic radiography to local the obstruction
Surgery – for obstructions caused by adhesions, volvulus, hernia or tumor (a colectomy may be necessary for a tumor

15. Intestinal Obstruction (cont.)
Nursing management- NG tubes relieves symptoms by decompressing or removing gas, intestinal contents and mucous
If surgery is required, normal postoperative care for patients recovering from abdominal surgery

16. Abdominal and Inguinal Hernia
Defect in muscular wall of the abdomen- intestine may break through - hernia
Etiology and pathophysiology-locations
Center of abdomen (umbilicus)
Lower abdomen (femoral, inguinal )
Reducible (can be pressed back into place)
Irreducible (wedged cannot be pressed back)
Strangulated/incarcerated(can’t replace and blood supply is cut off)

17. Types of Hernias
See Figure 29-3 on p. 677.

18. Hernias
Signs and symptoms – if not incarcerated, abnormal swelling out from the abdominal wall or groin. Some pain if the hernia is incarcerated –the flow of intestinal contents may be obstructed.
Surgery - defect in muscle closed with sutures- if weak area is large – use hernioplasty (synthetic material mesh) to reinforce the area

19. Diagnosis and Treatment of Abdominal and Inguinal Hernias
Nursing management
Care after hernia repair is directed at pain control and preventing recurrence of the hernia.
The patient is cautioned not to do heavy lifting, pulling, or pushing that increases intra-abdominal pressure.
Give a list of activities to avoid until healing is complete.

20. Bowel Ischemia
Etiology and pathophysiology –blood supply insufficient due to emboli, thrombosis or narrowing of vessels.
Signs and symptoms – sudden onset severe abdominal pain. N&V, diarrhea, cramps
Diagnosis- abd tender to palpation, bowel sounds minimal or absent. WBC up, confirm with CT/MRI scan

21. Bowel Ischemia
Treatment- NPO – NG tube to relieve distention, thrombolytic therapy, IV heparin.
Nursing management – IV hydration, foley cath, log input/output

22. Ulcerative Colitis and Crohn’s Disease Inflammatory Bowel Disease
Etiology – genetic, more common among Jewish population, immunologic activity
Pathophysiology – immunologic response to an etiologic agent. Inflammation of mucosal lining
Signs and symptoms
Attacks of diarrhea that may be bloody and contain mucus, abdominal pain with cramping, malaise, fever, and weight loss
Bouts often are precipitated by undue physical or emotional stress.

23. Ulcerative Colitis and Crohn’s Disease
UC – inflammation with formation of ulcers of the mucosa of the colon
Crohn – chronic inflammation any part of GI tract, usual proximal colon or distal ileum
Diagnosis
Colonoscopy
Flexible sigmoidoscopy
Mucosal biopsy
Barium enema
Stool analysis
Treatment
Medications
Diet modifications
Evidence-based therapies
Surgery

24. Comparison of Ulcerative Colitis and Crohn’s Disease (Table 29-2) page 678
Area affected
Characteristics
Signs and symptoms
Complications
See Table 29-2 on p. 678.

25. Comparison of Ulcerative Colitis and Crohn’s Disease (Cont.)
See Figure 29-4 on p. 679.

26. Treatment for Ulcerative Colitis or Crohn’s Disease
Varies according to severity of symptoms and chronicity
Conservative approaches
Low-fat, low-fiber, high-protein diet
Small, frequent feedings
Avoid lactose
Corticosteroids
Fluid replacement or blood transfusions, as needed

27. Crone’s disease

28. Expected Outcomes
Patient’s pain will be controlled with analgesia within 8 hours.
Patient will regain fluid balance within 36 hours.
Patient will experience decreased number of diarrhea bowel movements within 24 hours.
Long-term goals may be concerned with helping the patient adhere to the prescribed regimen, encouraging effective coping mechanisms, and participating in prescribed psychotherapy.

30. Audience Response Question 1
The recommended diet for patients with inflammatory bowel disease includes a combination of (Select all that apply.)
1. low fat.
2. high fiber.
3. high protein.
4. low calorie.
5. lactose avoidance.
Correct Answer: 1, 3, and 5

31. Audience Response Question 2
Which statement(s) regarding Crohn’s disease would be considered true? (Select all that apply.)
1. “It affects the full thickness of the small intestine.”
2. “It manifests as bloody diarrhea with abdominal cramping.”
3. “There is a cobblestone appearance on radiographs.”
4. “Pseudopolyps are found on the affected segments.”
5. “There is a greater risk for colon cancer.”
Correct Answer: 1 and 3

32. Appendicitis page 680
Etiology and pathophysiology – inflammation of the appendix
Signs and symptoms
Pain in the lower right side, halfway between the umbilicus and the crest of the ileum at McBurney’s point, is the best-known symptom of appendicitis.
Diagnosis – slight temp, increase WBC, CT or ultrasound

33. Appendicitis
Treatment – surgery ..if abscess is present, IV ABT may be given for several days prior
Nursing management – post operatively pain is the primary problem.

34. appendicitus

35. Audience Response Question 3
The nurse admitting a 23-year-old patient with possible appendicitis should anticipate which sign(s) and symptom(s)? (Select all that apply.)
1. Increased red cell count
2. Abdominal tenderness
3. Anorexia and vomiting
4. Mild fever
5. Board-like rigidity
Correct Answer: 2, 3, and 4

36. Peritonitis page 680
Etiology- inflammation of the peritoneum ruptured organs contents (with bacteria) spills into abdominal cavity
Pathophysiology – inflammation, swelling, serous fluid, peristaltic action of intestines slows or ceases
Signs and symptoms
Diagnosis and treatment
Nursing management

37. Peritonitis page 680
S/S – N&V, severe abdominal pain and distention. Shock. Peritonitis can be fatal.
Diagnosis – s/s, labwork, CT scan
Treatment – broad spectrum ABT, IV fluids and electrolytes. Surgery to repair ruptured organ.
Nursing mgt- pain mgt, HOB up semi-Fowlers, vital signs every 15 min, auscultate for return of bowel sounds

39. Malabsorption page 681
Etiology and pathophysiology – nutritional deficiency
Lactose intolerance, celiac, chemotherapy
Signs, symptoms, and diagnosis
Steatorrhea (passage of stool that is bulky, frothy, and foul smelling and that usually floats in the toilet) upper and lower GI series endoscopy with biopsy
Treatment- underlying cause of the intestinal mucosa malabsorption – gluten, lactose, etc.
Nursing management – teaching about diet and medications

40. Cancer of the Colon page 682
Etiology
Most at risk include those with disorders of the intestinal tract, especially ulcerative colitis and familial polyposis.
Other risk factors: smoking, alcohol consumption, physical inactivity, obesity, diet high in saturated fat or red meat, and inadequate intake of fruits and vegetables

41. Cancer of the Colon (cont.)
Pathophysiology
Signs and symptoms
Any change in bowel habits, either diarrhea or constipation, could be a sign of colon cancer.
Red blood in stool, black tarry stool, change in stool shape
Diagnosis
Screening tests
Colonoscopy
Transrectal ultrasound
Carcinoembryonic antigen- is elevated in 70% patients – but used to monitor treatment not for diagnostic purposes

42. Cancer of the Colon (Cont.)
Treatment
Surgical removal of the affected portion of the intestine
Colectomy (removal) or hemicolectomy(removal of one half of the colon
Abdominoperineal resection –entire rectum,anus & regional lymph nodes & part of the colon – permanent colostomy
Adjunctive treatment—preoperative, intraoperative, or postoperative radiation and chemotherapy
Nursing management – support and education of patient regarding surgery

43. Ostomy Surgery and Care
A colostomy may permanent or temporary. Colostomies are identified by their location and whether there are one or two stomas.
See page 684 Fig 29-5, 29-6
Loop colostomy – loop of colon adhere to abd wall and slit. One stoma. Reversible
Double-barreled colostomy – Loop of intestine is completely severed. Two stomas. Reversible.
Single-barreled or end colostomy – colon end brought to abd surface permanent or temporary with one stoma

44. Types of Ostomies and Intestinal Diversions
temporarymporary
See Figure 29-6 on p. 684.
permanent

45. Preoperative Nursing Care
Low-residue diet as early as 7 to 10 days before surgery. The last 24 to 72 hours before surgery, the diet is changed to liquids only.
Vitamins and minerals may be given to supplement these restricted diets.
Antibiotics may be given as prophylaxis against infection of the operative site.
Laxatives and enemas
Nasogastric (NG) tube and Miller-Abbott tube

46. Nursing Management of Ostomies
Immediate postoperative care
Psychosocial assessment
Care of the stoma
A noticeable lightening or blanching of the stoma
Signs of edema
Fecal output
Dressing
DARK PURPLE OR BLACK STOMA COLOR SHOULD BE REPORTED IMMEDIATELY

47. Care of the Stoma Measurement of intake and output
Evacuation and irrigation
Cultural issues for ostomy patients
Periostomal skin care
Cleanliness
Provision of a protective barrier
Changing the collection device – usually twice a week to maintain an effective seal
Psychosocial concerns – body image

48. Ostomy Collection Appliance
See Figure 29-8 on p. 688.
From deWit SC, O’Neill P: Fundamental concepts and skills for nursing, ed. 4, St. Louis, 2013, Saunders.

49. Patient Teaching
Preventing intestinal blockage for the ileostomy patient – SEE PAGE 689 – Patient Teaching
What to do when there is a blockage in the intestine or the ostomy –SEE PAGE 689 – Patient Teaching

50. Hemorrhoids
Etiology and pathophysiology varicosities of the veins of the rectum – internal or external
Signs, symptoms, and diagnosis – local pain and itching. External hemorrhoids are less likely to bleed. Physical exam is diagnosis.
Treatment – correcting constipation, local applications anesthetic, sitz baths, laser surgery
Nursing management – hydrocortisone suppositories, pillow (NOT ring shaped device)

51. Pilonidal Sinus (Pilonidal Cyst)
Etiology – lesion in cleft of buttocks
Pathophysiology-injury, obesity, improper cleansing of area
Signs and symptoms – infection with pain in area, swelling and drainage from site
Diagnosis – visual exam
Treatment – drainage, pack in cavity
Nursing management – removal of packing, cleansing, site care.
ANTIBIOTICS DO NOT HEAL A PILONIDAL CYST

53. Anorectal Abscess and Fistula
Etiology – abscess, mucosal tears in rectum lead to fistula formation
Pathophysiology – hard stools, constipation, 50%Crohn’s patients develop fistula
Signs and symptoms – discharge of pus from fistula, pain at site
Diagnosis – physical exam
Treatment – pain meds, surgery
Nursing management - education