1/3/2008. Karen Burke Priscilla LeMone Elaine Mohn-Brown. Medical-Surgical Nursing Care, 2e Karen Burke, Priscilla LeMone, and Elaine Mohn-Brown

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Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 20 Caring for Clients with Bowel Disorders Diarrhea

db bowel surface Increased water secretion: osmosis, infection, unabsorbed fat, medications Diarrhea Manifestations Depend on the cause, duration, severity, and

1 Medical-Surgical Nursing Care Second Edition Karen Burke Priscilla LeMone Elaine Mohn-Brown Chapter 20 Caring for Clients with Bowel Disorders Diarrhea Pathophysiology Result from impaired water absorption or increased water secretion into the bowel Increased water absorption: increased peristalsis or decreased db bowel surface Increased water secretion: osmosis, infection, unabsorbed fat, medications Diarrhea Manifestations Depend on the cause, duration, severity, and area of bowel affected Complications Loss of water and electrolytes Dehydration, hypovolemic shock Potassium, magnesium, and bicarbonate loss can lead to metabolic acidosis 1

2 Diarrhea Management Identify and treat underlying cause Diagnostic tests Dietary management Medications Constipation Pathophysiology Organic cause tumor or partial bowel obstruction Lifestyle and psychogenic causes Habitual use of laxatives Constipation Manifestations Fecal impaction Watery mucus Full sensation in rectum with abdominal cramping 2

3 Management Digital exam of rectum Diagnostic tests Dietary management Medications Enemas Constipation Irritable Bowel Syndrome Pathophysiology CNS innervation altered Affected by eating, hormones, stress, drugs Sensory responses increased Increase in mucous production Irritable Bowel Syndrome Manifestations Change in frequency, consistency of stools 3

4 BOX 20-5 Manifestations of Irritable Bowel Syndrome. Irritable Bowel Syndrome Management Diagnostic tests Stool specimen Sigmoidoscopy Colonoscopy Small-bowel series Irritable Bowel Syndrome Treatment Relieve symptoms Reduce or eliminate precipitating factors 4

5 Fecal Incontinence Pathophysiology Physiologic and psychologic factors BOX 20-7 Selected Causes of Fecal Incontinence. Fecal Incontinence Manifestations Loss of voluntary control of defecation Management Directed at cause Measure to either ih reduce diarrhea or constipation i Exercises for pelvic floor muscle tone Bowel retraining program Establish daily routine for bowel evacuation 5

6 Pathophysiology Celiac disease Lactose intolerance Bowel resection Short bowel syndrome Manifestations Depends on the cause Malabsorption BOX 20-8 Manifestations of Malabsorption. Management Find and treat the cause Malabsorption 6

7 Appendicitis Pathophysiology Obstruction with fecalith Distention Pressure leads to impaired blood supply Leads to inflammation, edema, ulceration, infection hours necrosis Classified by stages Appendicitis Manifestations Generalized or upper abdominal pain Localizes in right lower quadrant Aggravated moving, walking, coughing Localized and rebound dt tenderness Right hip extension increases pain Low-grade fever, anorexia, nausea, vomiting Appendicitis Complications Perforation Management Prompt diagnosis and management to prevent perforation Hospitalization, i IV fluids, NPO until diagnosis i confirmed Diagnostic tests Surgery 7

Peritonitis Pathophysiology Bowel contents enter a sterile abdominal cavity Generalized inflammation of the abdominal cavity Third spacing Paralytic ileus Manifestations Depend

8 Peritonitis Pathophysiology Bowel contents enter a sterile abdominal cavity Generalized inflammation of the abdominal cavity Third spacing Paralytic ileus Manifestations Depend on severity and extent of the infection BOX Manifestations of Peritonitis. Peritonitis Complications Life-threatening, localized, systemic Abscess formation Septicemia Shock 8

9 Management Diagnostic tests Intestinal decompression Antibiotics Surgery Peritonitis Ulcerative Colitis Pathophysiology Inflamed mucous membranes bleed easily Mucous membranes ulcerate, slough, get lost in the feces Scar tissue forms; bowel thickens and shortens Ulcerative Colitis Manifestations Gradual onset of diarrhea and bleeding Intermittent rectal bleeding and mucous Dehydration, malnutrition Urgency, cramps, Fatigue, anorexia, weakness 9

10 Ulcerative Colitis Complications Perforated colon Toxic megacolon High risk for colon cancer Crohn s Disease Pathophysiology Inflammatory lesions of bowel mucosa Ulcers and deep fissures develop Fistula formation Scarring, narrowing Rubber hose appearance Crohn s Disease 10

11 Crohn s Disease Complications Intestinal obstruction Abscess Fistula formation Increased risk cancer of colon Crohn s Disease Manifestations Diarrhea Abdominal pain, palpable mass Lesions of the rectum, anus Ulcerative Colitis and Crohn s Disease Management Manage symptoms Control disease process Supportive care Diagnostic tests t Medications Dietary management Surgery 11

The distribution and frequency of colorectal cancer.

12 Colorectal Cancer Pathophysiology Begin as benign polyps Grows undetected in the colon or rectum Figure The distribution and frequency of colorectal cancer. Colorectal Cancer Pathophysiology Direct extension into the bowel wall Spread to neighboring organs Seed other organs Metastasis t 12

13 Colorectal Cancer Manifestations Bleeding with defecation Change in bowel habits Pain, anorexia, weight loss Prognosis depends d on extent t of the disease Colorectal Cancer Complications Bowel obstruction Perforation into neighboring organs Management Annual screening beginning at age 50 Diagnostic tests Surgery Adjunctive therapy Bowel Obstruction Pathophysiology Mechanical or functional Adhesions, tumors, twisted bowel Paralytic ileus Gas and dfl fluid are trapped di in the bowel Distention, pressure, ischemia, necrosis, hypovolemia, shock 13

14 Bowel Obstruction Manifestations Progressive crampy or colicky pain Vomiting Loud bowel sounds, at first Reduced bowel sounds, abdomen distended and tender Complications Hypovolemic shock Strangulated colon Bowel Obstruction Management Diagnostic tests Gastric decompression Surgery Hernia Pathophysiology Protrusion of an organ or structure through the muscular wall of the abdomen Described by location Pain radiating to groin Reducible Irreducible Incarcerated Strangulated 14

15 Hernia Hernia Management Diagnosis made if able to reduce or manipulate Surgery Diverticular Disease Pathophysiology Inflammation and perforation of a diverticulum Infection, perforation 15

16 Diverticular Disease Manifestations Pain Constipation, diarrhea, nausea, vomiting, low-grade fever Diverticular Disease Management Nothing prescribed prior to surgery Diagnostic tests High fiber diet Bowel rest Antibiotics Hemorrhoids Pathophysiology Distended rectal veins caused by straining, pregnancy, prolonged sitting, obesity, chronic constipation, low-fiber diet Internal External 16

17 Hemorrhoids Manifestations Pain, rupture, bleeding Hemorrhoids Management Conservative Diagnostic tests Medications Sclerotherapy Hemorrhoids 17

18 Anorectal Lesions Fissures Abscess Fistula Pilonidal disease Diarrhea Nursing Care Identify the cause Relieve the symptoms Prevent complications Prevent spread of infection Diarrhea Teaching Teach causes and preventative measure Infection control Purification of water for travel Fluid replacement Chronic diarrhea 18

Teaching Diet high in natural fiber High fluid intake

19 TABLE 20-1 Foods that may Aggravate Chronic Diarrhea. Constipation Relieve constipation Prevent reoccurrence Teaching Diet high in natural fiber High fluid intake Exercise Normal bowel habits Use of laxatives Avoid straining Constipation 19

20 Irritable Bowel Syndrome Nursing Care Same as that for diarrhea and constipation Teaching Symptoms are real Discuss related df factors Relationship between stress and manifestations Stress reduction techniques Irritable Bowel Syndrome Teaching Psychologic factors Dietary influences Exercise Dietary patterns Notification of PCP with any changes Fecal Incontinence Teaching Often treatable Constipation teaching Bowel retraining instructions Importance of good skin care 20

21 Malabsorption Nursing Care Effects on nutrition and bowel patterns Nutritional status Weight, fatfold measurements, lab data, dietary intake Enteral lf feeding supplements as prescribed Intake/output, daily weights, skin turgor, mucous membranes Frequency stools Medications Skin care Malabsorption - Teaching Daily management Diet Medication regime Reading labels Fluid intake Exercise Daily weights Manifestations to report to physician Dietician or counselor referrals Appendicitis Nursing Care Pain: onset, severity, duration Food Fluids Allergies Medications Teaching Preop teaching: turn, coughing, deep breathing, pain management 21

22 Peritonitis Nursing Care Intensive nursing and medical interventions Teaching Wound care, dressing changes Needed dd supplies Medications S/S further infection Activity restrictions Ulcerative Colitis and Crohn s Disease Nursing Care Manage diarrhea Psychosocial effects Ulcerative Colitis and Crohn s Disease Teaching Disease process, effects, stress Treatment options Medications Complications, management Diet Nutritional supplements Fluids Exercise Teaching for surgery 22

23 Colorectal Cancer Nursing Care Provide emotional support Teaching Surgical needs Colorectal Cancer Teaching Prevention American Cancer Society recommendations Regular health examinations Tests and procedures Ostomy care Pain and symptom management Bowel Obstruction Nursing Care Preventing complications from obstruction and surgery Teaching Wound care, activity level 23

24 Nursing Care Preoperative assessment Postoperative care Teaching Risk ikf factors Surgical intervention Pain management Activity restrictions Hernia Diverticular Disease Teaching Diet Food and fluid limitations Postoperative instructions as necessary Teaching Fiber, fluids, exercise Constipation management Complications Postoperative ti teaching Hemorrhoids 24

25 Teaching Diet Fluids Prevent constipation Post operative care Anorectal Lesions Diarrhea Stool count Abdominal girth Medications Food intake Diarrhea Risk for Deficient Fluid Volume Risk for Impaired Skin Integrity 25

26 Evaluation Stool frequency Nutritional status Weight Fluid volume status Skin integrity Monitor electrolytes Diarrhea Constipation Normal defecation pattern Diet, fluid intake, activity Abdominal shape, girth, bowel sounds, tenderness Warm water Dietary consult Provide stool softeners as prescribed Fecal Incontinence Bowel Incontinence Daily bowel evacuation time Glycerine suppository use Caring, nonjudgmental manner Risk for Impaired Skin Integrity Skin care Frequent change of incontinence pads 26

27 Appendicitis Ineffective Tissue Perfusion: Gastrointestinal Signs of perforation Vital signs IV fluids Postop care Pain Pain assessment Prescribed analgesics Effectiveness of pain medication Alternative methods of pain relief Appendicitis Evaluation Teach wound/incision care Wound assessment instructions Dressing changes Hand washing What to report to the physician Activity restrictions Driving, return to work Home care nurses Assessment Monitor current status Progress of recovery Identify complications Peritonitis 27

BOX 20-11 Assessment: Assessing Clients with Peritonitis.

weight, skin turgor, mucous membranes Lab values, H&H, specific gravity, serum electrolytes Fluid and electrolyte

28 BOX Assessment: Assessing Clients with Peritonitis. Peritonitis Pain Positioning Analgesics Pain management techniques Deficient Fluid Volume Vital signs, I&O, weight, skin turgor, mucous membranes Lab values, H&H, specific gravity, serum electrolytes Fluid and electrolyte replacements Good skin care Frequent oral hygiene Peritonitis Ineffective Protection Monitor signs of infection Cultures as ordered Hand washing Fluid balance and nutrition 28

29 Peritonitis Anxiety Level and coping skills Calm manner Reduce changes in caregiver assignments Explain all procedures Teach and assist with measures to reduce anxiety Peritonitis Evaluation Pain level Weight Urine output Documentation ti Wound healing Ulcerative Colitis and Crohn s Disease Assessment Current health status Complications Psychosocial factors 29

BOX 20-14 Assessment: Assessing Clients with Inflammatory Bowel Disease.

and output VS every 4 hours Daily weights Fluid intake Skin care Ulcerative Colitis and Crohn s Disease Imbalanced Nutrition: Less than Body

30 BOX Assessment: Assessing Clients with Inflammatory Bowel Disease. Ulcerative Colitis and Crohn s Disease Diarrhea Amount and frequency Medications Skin assessment Risk for Deficient Fluid Volume Accurate intake and output VS every 4 hours Daily weights Fluid intake Skin care Ulcerative Colitis and Crohn s Disease Imbalanced Nutrition: Less than Body Requirements Food intake Dietary consult Parenteral nutrition Monitor laboratory values Disturbed Body Image Encourage exploration of feelings Discuss treatment options Teach coping strategies Nonjudgmental care Support group 30

31 Ulcerative Colitis and Crohn s Disease Evaluation Number of daily stools Skin integrity Hydration Wiht Weight Diet/intake Coping Colorectal Cancer Assessment Effects of the disease Treatment Client s ability to function and maintain ADLs Colorectal Cancer Pain Use pain scale to assess pain level Effectiveness of pain medication Abdominal assessment Administer i analgesics Nonpharmacologic pain measure Splinting 31

32 Colorectal Cancer Anticipatory Grieving Trusting relationship with patient Encourage expression of fears Coping mechanisms Support groups Risk for Sexual Dysfunction Express feelings Social services Ostomy society Colorectal Cancer Evaluation Pain levels Evaluate pain measures Responses to disease and treatments Bowel Obstruction Assessment Assess for bowel sounds, distention Assess for complications 32

33 Bowel Obstruction Deficient Fluid Volume Monitor vital signs and CVP Intake and output, urine output, gastric output Measure abdominal girth Ineffective breathing pattern Respiratory rate, lung sounds Respiratory support Bowel Obstruction Evaluation Abdominal girth Bowel sounds Pain Tolerance Fluid volume status Potential complications Hernia Risk for Ineffective Tissue Perfusion: Gastrointestinal Comfort measures Bowel sounds Signs of strangulation 33

Chapter 34. Nursing Care of Patients with Lower Gastrointestinal Disorders

Chapter 34. Nursing Care of Patients with Lower Gastrointestinal Disorders Chapter 34 Nursing Care of Patients with Lower Gastrointestinal Disorders Lower Gastrointestinal System Small Intestines Large Intestines Rectum Anus Constipation Fecal Mass Held In Rectum Feces Become