1. Care of Patients with Noninflammatory Intestinal Disorders
Chapter 59
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-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

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 adenomatous polyposis)and HNPCC (herediary nonpolyposis 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 trauma caused 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’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.

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%
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.

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
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).

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.
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),

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
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.

43. 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.