Management of Clients with Intestinal Disorders NRS 108 SPRING 2008 LOLA OYEDELE MSN,RN,CTN MAJUVY SULSE MSN, RN, CCRN

Management of Clients with Intestinal Disorders

NRS 108SPRING 2008

LOLA OYEDELE MSN,RN,CTNMAJUVY SULSE MSN, RN, CCRN

General Clinical Manifestations

Hemorrhage Pain Nausea and vomiting Distension Diarrhea Constipation Abnormalities in fecal content

Inflammatory Disorders

Infections and Infestations Viral and Bacterial Infections

Gastroenteritis Appendicitis Peritonitis Diverticulitis Parasitic infections Irritable bowel syndrome Crohn’s disease and ulcerative colitis

Gastroenteritis

Inflammation of the stomach and intestinal tract

Affects primarily the small bowel

Etiology and Risk Factors

Transmitted by the fecal oral route Person to person Ingestion of fecally contaminated food and

water Food is usually the vehicle for transmission Common bacteria sources of contaminated

food include eggs (salmonella), undercooked meat (E. Coli)

The incubation period for all viral and bacterial infections

Ranges from 6 hours to 3 – 4 days.

Gastroenteritis

Pathophysiology

Intestinal flora is disrupted by harmful bacteria and viruses or antibiotic therapy

Pathogens cause tissue damage and inflammation

Release of endotoxins causes greater secretion of water and electrolytes

Inhibition of Na absorption takes place caused by secretion of chloride and bicarbonates

In order to create a Na balance, large amounts of protein rich fluids are secreted in the bowel overwhelming the large bowel’s ability to reabsorb the fluid leading to diarrhea

Pathophysiology

Manifestations

Manifests as diarrhea abdominal pain cramping

Associated symptoms are nausea, vomiting, fever, anorexia, distension, tenesmus (straining on defecation) and hyperactive bowel sounds

Prognosis

Temporarily disabling and self limiting for 2-3 days Resolves in 1-5 days Can be fatal in debilitated, older or very young people Early detection and treatment with fluid and

electrolytes are critical in preventing death or disability

Clients with E. coli may end up with hemolytic uremic syndrome which causes death

Parasitic Infection (Helminths)

The intestinal tract may be infected with any of several helminths or parasitic worms e.g. roundworms, pinworms trichinella spiralis that causes trichinosis and species of tape worm.

Contracted through the skin or ingestion of contaminated food or water

May cause UTI or pruritus ani Susceptible to medications

Outcome management for viral bacterial and parasitic infections Rest the Bowel

NPO until vomiting stops

Decrease diarrhea Obtain stool specimen if unresolved for 2-

3days Anti-Infective agent Avoid meds. that will decrease intestinal

motility

Outcome Management for Viral Bacterial and Parasitic Infections Restore fluids and electrolytes

Small amount of clear liquid as tolerated Electrolyte beverage may be given Advance diet in 24hrs. as tolerated In severe fluid depletion start IV 0.45% NACL A potassium supplement may be ordered if K+

is low.

Nursing Management of the Medical Client Assess the stool for color, odor, consistency,

frequency and amount Assess bowel sounds, muscle weakness and fatigue Examine anal area for irritation, clean the area and

apply moisture barrier Administer anti-infective agent Replace fluid and electrolytes Provide discharge teaching

Appendicitis

An inflammation of the vermiform appendix Most common in adolescence Can occur at any age but rare in children

under 2 years Not common in older adults Rupture occurs mostly in older adults


Caused by a fecalith that occludes the lumen Kinking of the appendix Swelling of the bowel wall Fibrous conditions of the bowel wall External occlusion of the bowel by adhesions

Pathophysiology

Due to obstruction, the intraluminal pressure increases leading to decreased venous drainage, thrombosis, edema and bacterial invasion of the bowel wall

Following initial obstruction, the appendix becomes increasingly hyperemic, warm, and covered with exudates, progressing to gangrene and perforation

Clinical Manifestation

Vomiting which begins after the pain starts Loss of appetite Low grade fever Coated tongue Bad breath Elevated WBC (10 -15,000/mm3) Pain at McBurney’s point confirms diagnosis

APPENDICITIS

DESCRIPTION Inflammation of the

appendix When the appendix

becomes inflamed or infected, rupture may occur within a matter of hours, leading to peritonitis and sepsis

MCBURNEY’S POINT

Surgical Management

Appendectomy Done within 24 – 48hrs. Of onset of

manifestation Can be done through a small incision or a

laparoscope Delay will result in rupture of the appendix

leading to peritonitis

Complications and Outcomes

Bowel perforation Antibiotics and surgical drainage is the

treatment Peritonitis D/C within 24-48 hrs. Lifting is restricted for 2-4 weeks Resume all activities in 4-6 weeks

Nursing Management of the Surgical Client Assessment Pain management Fluid and electrolyte replacement Manage the risk for infection

Peritonitis

Inflammation of the peritoneal membrane

Causes sharp well localized pain


May be primary or secondary Sources include G.I., external environment

and blood stream Offending organism is E. Coli No none risk factors

Causes of Peritonitis

Ruptured or gangrenous gall bladder Perforated peptic ulcer Perforated stomach or intestine secondary to

cancer or inflammatory bowel disorder, bowel obstruction, penetrating wounds and acute pancreatitis

Early diagnosis is key

Pathophysiology

The inflammatory response diverts blood to the inflamed area of the bowel

Peristaltic activity of the bowel ceases Fluids and air are retained within the lumen

raising the pressure and increasing fluid secretion into the bowel

Circulating blood volume diminishes

The inflammatory process increases oxygen requirements

Difficulty in breathing results relative to abdominal pain and increased abdominal pressure

Pathophysiology


Varies according to the cause

Pain – localized or generalized increasing with pressure

Rigidity of the abdominal muscle

Nausea and vomiting

Low grade fever Absence of bowel

sounds Shallow respiration Increased WBC

(20,000mm3) X-ray shows edema and

dilation of the intestines

Outcome Management

Maintain fluid and electrolyte NGT IV fluid

Control infection IV ABT Surgical repair and drainage

Nursing Management

Obtain history Asses the abdomen for positive bowel

sounds, firmness, distension or rigidity IV antibiotics Surgical drainage and repair of perforation

Post Operative Care

Monitor for complications e.g. ARDS, sepsis and shock

Monitor fluid and electrolyte balance

Check vital signs, bowel sounds, urine output, skin tugor, mucus membrane and weight

Report manifestation of sepsis, oliguria, elevated temperature or drop in blood pressure

IV fluid and antibiotics Discharge teaching

Inflammatory Bowel Disease

Crohn’s disease

Chronic relapsing disease Develops discontinuously

(without sequence) in any part of the alimentary tract

Most common location is the terminal ileum

Involves the entire thickness of the bowel wall

Mortality rate is not high Recurrence and complications

can lead to disability More common in whites and

Ashkenazi Jews


The cause of Crohn’s disease is unclear There appears to be a genetic or heredity

predisposition Considered to be autoimmune disease There are no preventive measures for

Crohn’s disease Only risk is genetic

Pathophysiology of Crohn’s disease

Characterized by inflammation of segments of the digestive tract

Inflammation usually extends through all layers of the intestinal mucosa; this can lead to such complications as obstruction, tears, bleeding (anemia), and malnutrition

Consist of quiet (remission) and active (relapse) periods. In quiet periods, the patient is asymptomatic, in active periods, the patient experience symptoms

The cause is unclear although there appears to be a genetic or hereditary predisposition

Diagnosis

Thorough history and physical examination CBC Serum chemistry Stool for occult blood Barium studies Endoscopy with biopsy

Symptom’s of Crohn’s Disease

Stool may be foul smelling and fatty due to malabsorption (Steatorrhea)

Intermittent or chronic abdominal pain Diarrhea, may contain blood or mucous Stool is soft and semi solid Unexplained weight loss Anorexia, anemia Fatigue

Indications for Surgery

Fistula Abscess Obstruction Malignancy Bleeding

Ulcerative Colitis

A disease that spans the entire length of the colon

Involves only the sub mucosa and mucosa

Begins in the rectum and distal colon spreading upward to the sigmoid and descending colon

Causes inflammation, thickening, congestion, edema and minute lacerations that ooze blood

Develops into an abscess Bleeding from minor trauma More common than Crohn’s disease Occurs in all ages Higher incidence among young adults,

women and Jews Familial tendency

Ulcerative Colitis


Bacterial origin Allergic reaction Altered immune state Presence of antibodies in the colon Emotional disturbance can precipitate an

exacerbation or prolong an attack No preventable risk factors

Pathophysiology of Ulcerative Colitis

Appearance depends on the stage, activity and severity

Characterized by a crypt abscess (Inflammatory)

Secretions from crypt abscess result in purulent discharge from the bowel mucosa.

Abscess becomes necrotic and ulcerates

Inflammation reaction due to secondary infection leads to scarring, fibrosis, narrowing, thickening and shortening of the colon


Abdominal pain Diarrhea (20x/day) Fluid imbalance Weight loss Metabolic acidosis Rectal bleeding Tenesmus Bloody stool

Sense of urgency Cramping Colicky pain in the LLQ Nausea, vomiting,

anorexia Anemia Low potassium May recur with

emotional distress

Medical Management

Decrease diarrhea Replace fluid, electrolytes and blood as

needed Restrict physical activity during attack to

decrease intestinal motility Keep record of loose stool, consistency, color Bowel rest/parenteral hyper alimentation Restore immuno competence Correct nutritional deficiency Relieve bowel edema and inflammation

Pharmacological Agents

Antidiarrhea medications e.g. Imodium, Lomotil

Metamucil may improve consistency of stool and control incontinence

Aminosalicylates – inhibits prostaglandin synthesis e.g. Azulfidine, Mesalamine and Olsalazine

Anti infective agents – prevent or control infection

Corticosteroids – reduce body’s response to inflammation e.g. prednisone, hydrocortisone

Give folic acid supplement Immunosuppressive

agents Anticholinergics – relieve

abdominal cramp and control diarrhea

Nutritional Support

Increase nutritional intake Diet and supplement – High protein, high

calorie, low residue diet. TPN Avoid cocoa, chocolate, citrus fruit,

carbonated drinks, nuts, seeds, popcorn and alcohol

Nursing Management

Assessment Control diarrhea Altered nutrition Pain management Ineffective individual coping

Surgical Management

Surgery is the only cure Indicated when medical management fails Total Proctocolectomy

Permanent ileostomy is formed Ileorectal Anastomosis Continent ileostomy Surgical resection of the small bowel

Continent Ileostomy

Reservoir is constructed from a loop of colon Advantages

No need for external pouch Minimal skin problems No flatus or leakage of stool

Client drains the pouch several times a day using a catheter usually in response to a feeling of fullness

Contraindications

Crohn’s disease Malnutrition

Complications

Suture line leakage Peritonitis Fistula formation Obstruction by food residue

Outcomes

Resume activity in 4-6weeks Improved nutritional status Improved quality of life

Ileal Pouch-Anal Anastomosis

Preferred surgical procedure for clients with ulcerative colitis

Colon is removed Ileoanal reservoir is created Temporary loop ileostomy is formed Heals in 3-4 months Ileostomy is revised so that stool drains

into the reservoir

Contraindications Crohn’s disease Malnutrition

Complication Anastomotic leakage Pouchitis - inflammation of the pouch Bowel obstruction

Outcome Resume regular activities in 4 – 6 weeks Improved nutritional status Improved quality of life

Ileal Pouch-Anal Anastomosis

Surgical Resection of the Small Bowel Indication

Crohn’s disease to treat complications Contraindication

Malnutrition – give TPN Complications

Impaired absorption of vit.B12, glucose, fat and protein Loss of body protein or lean body mass Anemia Paralytic ileus

Outcome Return to regular activities and complete

wound healing Adequate nutritional in 4-6weeks after

surgery

Surgical Resection of the Small Bowel

Nursing Management

Assessment – Nutritional status and start TPN if needed

Pre – op. teaching visit from a member of the ostomy association Wear pouch for 1-2 days before surgery

Post – op teaching Monitor stoma Advance diet Monitor for complications

Critical Thinking

What are the signs of intestinal obstruction? Anorexia Abdominal cramps Absence of ileostomy drainage Foul brown watery discharge in the pouch Visible peristalsis

Risk for body image disturbance Confront the stoma Integrate function and appearance into their

body image Help client look at the stoma and touch it as

soon as possible Discuss clothing options Discourage wearing a tight waist band Verbalize feelings

NURSING DIAGNOSIS

Ineffective Management of Therapeutic Regimen Self care Stoma assessment Prevent skin irritation Reduce odor Discuss medications Emphasize fluid intake Prevent urolithiasis

Encourage follow up visits

Maintain ileal drainage Continent ileostomy:

Reservoir Catheterization

Continent ileostomy Explain dietary

recommendations

Risk for sexual dysfunction Verbalize concerns Empty pouch before intimacy Use different positions Pregnancy and vaginal delivery is possible

for clients with ileostomy

NURSING DIAGNOSIS

Self care Teach stoma care before discharge Join united ostomy association Know nearest ostomy supply center Visiting nurse or enterostomal therapy nurse

should visit the client at home to follow up on learning needs

Wear a medical alert identification bracelet

NURSING DIAGNOSIS

Colorectal Cancer

Etiology and Risk Factors Cause is unknown Related to low residue, high fat and highly refined

foods with inadequate intake of fruits and vegetables

Higher incidence in cities and industrialized countries

Genetic mutation in hereditary form of colon cancer Familial tendency Increased risk with age and ulcerative colitis or

familial polyps

Pathophysiology

Develops from adenomatous polyps Increases in size and invade bowel wall. Tumors in the right intestine tend to be bulky and

cause necrosis and ulceration Left tumors are small that cause ulceration of the

blood supply Spread by direct extension to nearby organs Lymphatic and hematogenous channels usually the

liver Seeding of cells into the peritoneal cavity

Clinical Manifestations

Rectal bleeding Change in bowel habits Abdominal pain Weight loss Anemia Anorexia

Prognosis

Depends on the health of the client Early diagnosis Effective treatment Early diagnosis and treatment are

essential for a good outcome

Outcome Management: Colorectal Cancer Medical Management

Decrease Tumor Growth, Chemotherapy, & Radiation

Surgical Management Colostomy Abdominal-Perineal Resection

Colostomy

Complications

Suture line leakage Peritonitis Hemorrhage Stomal necrosis Retraction Prolapse Stenosis

Outcome

Resume usual activities within 4 – 6 weeks Able to perform self care of the stoma Radiation and chemotherapy may be

continued if indicated

Outcome Management of Patient with Colorectal Cancer

Nursing Management Risk for Injury Risk for Ineffective Management of

Therapeutic Regimen: Ostomy Care, Irrigations, Minimizing Flatus

Nursing Management of the Surgical Client

Pre – Operative care History taking High calorie, protein, carbohydrate and low

residue diet TPN may be necessary Decrease risk of infection Treat anxiety if present Provide enterostomal education

Post Operative care Assessment Gastric suction Ensure patency of NGT Monitor colostomy output Assess stoma for signs of ischemia Assess incision site

Nursing Management of the Surgical Client

Risk for Injury

Monitor vital signs Advance diet Decrease cramping Apply rectal dressing Reduce pain Monitor stoma drainage Prevent thrombophlebitis

Risk for Body Image Disturbance

Provide emotional support and extensive teaching

Involve family and significant other in teaching

Risk for Ineffective Management of Therapeutic Regimen

Teach self care Teach client to empty pouch when it is about

½ full Teach stoma irrigation – done to regulate the

colostomy Minimize flatus

Herniations

Abnormal protrusion of an organ, tissue or part of an organ through the structure that normally contains it.

Occurs commonly in the abdomen


Occurs due to a defect in the integrity of the muscular wall

Increased intra – abdominal pressure. Obesity Heavy lifting and straining

Pathophysiology

Defects in muscular wall and increased intra abdominal pressure leads to herniation

Muscle weakness can be congenital, due to trauma or wide space at the inguinal ligament

Intra abdominal pressure increases with pregnancy, obesity, heavy lifting, coughing and trauma from blunt pressure

Types of Hernia

Reducible Irreducible or incarcerated Strangulated – surgical emergency

Classification

Indirect Inguinal hernia Direct Inguinal hernia Femoral hernia Umbilical hernia Incisional or ventral

hernia

Medical, Surgical, and Nursing Management Medical management

Reduction and truss Surgical management

Herniorrhaphy Nursing management

Check for voiding Return to general diet No lifting for 4-6weeks Apply ice pack to reduce pain and swelling

Diverticular Disease

Two diseases Diverticulitis

Blind out – pouching or herniation of intestinal mucosa through the muscular coat of the large intestine (sigmoid colon)

Diverticulosis The presence of non inflamed

diverticula

DIVERTICULA

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.

COMPLICATIONS OF DIVERTICULITIS

From Beare PG, Myers JL. Adult Health Nursing, ed. 3, St. Louis, 1998, Mosby.


Low fiber diet Presence of muscle weakness Diverticulitis occurs when undigested food

blocks the diverticulum

Pathophysiology

Weak points in the muscle of bowel exist where branches of blood vessels penetrate the colon wall

These weak points create areas for bowel protrusion when there is increased intraluminal pressure

It frequently develops in the sigmoid colon May be acute or chronic


Discomfort – dull, episodic or steady, left quadrant or mid abdominal pain

Alteration in bowel habits Increased flatus Anorexia Low grade fever Rectal bleeding Stool may contain mucus Tender mass on digital rectal exam

Outcome Management

Medical and Nursing Management Diet modification Increase fiber and prevent constipation Notify physician of change in bowel

habit Rest the colon Antibiotic therapy

Surgical Management Indicated when there is bleeding,

obstruction, abscess and perforation Colon resection with colostomy

Outcome Management

Obstructions

Partial or complete impairment of the forward flow of intestinal content

Etiology and Risk Factors:

Inflammation, Neoplasm, Adhesions, Hernia, Volvulus, Intussusception Food blockage

Compression from outside the intestine,

Paralytic ileus, Vascular problems such

as mesenteric embolus and thrombus,

Hypokalaemia may result in obstruction

Other Causes

Diverticulitis Ulcerative colitis Previous abdominal surgery

Causes of Intestinal Obstruction

Mechanical – Adhesions, hernias, Volvulus, Intussusceptions, cancers

Neurogenic – paralytic ileus Vascular

Interruption of blood flow Obstruction of blood flow Complete occlusion Partial occlusion


Vomiting Abdominal pain Visible peristalsis Toxemia High pitched tinkling

sound Hypoxia

Peritonitis Vomit may contain dark

fecal material (Small bowel)

Dehydration Metabolic acidosis

Diagnosis

X – ray shows gas shadows Barium or radiopaque studies CBC Leukocytosis ( Bowel Strangulation)

Outcome Management: Bowel Obstruction Medical

Decompress the bowel

NGT Nursing

Management Assessment Replace fluid and

electrolyte

Decompress the bowel Discharge teaching

Surgical Management Bowel resection Colostomy Bypass procedure

Irritable Bowel Syndrome

A functional disorder of motility of the intestine

Also called spastic colon or irritable colon


High fat diet High intake of fresh fruits, gas producing

foods, carbonated beverage and alcohol Smoking Lactose intolerance High stress Alteration in sleep and rest

Pathophysiology

A disorder of GI motility Motility may be altered by any number of

factors including diet and emotions. The alteration in motility can cause diarrhea,

constipation or alternating diarrhea and constipation


Abdominal pain Altered bowel function Constipation or diarrhea Hyper secretion of colon

mucus Flatulence Nausea Anorexia

Anxiety or depression Fiber, fruits, alcohol and

fatigue may aggravate or precipitate manifestation

Stool with mucus Foul breath Diagnosis is made by

excluding other diseases

Outcome Management:

Medical and Nursing Management Modify Diet – Increase bulk Modify Lifestyle – reduce stress Administer Medications – sedatives and

antispasmodic Alternative Treatments Provide empathy and support

Hemorrhoids

Perineal varicose veins May be external or

internal


Caused by Increased intra abdominal pressure

Pregnancy Constipation with prolonged straining Obesity CHF Prolonged sitting or standing Cirrhosis with portal hypertension

Pathophysiology

Tenesmus increases intra abdominal and hemorrhoidal veins pressure leading to distension of the veins

When the rectal pouch is filled with formed stool, venous obstruction occurs

The repeated and prolonged increase in this pressure and obstruction causes the hemorrhoidal veins to become permanently dilated.

As a result, thrombosis and bleeding may occur


Enlarged mass at the anus Bleeding and prolapse Rectal itching and constipation Pain Bright red blood in the stool

Outcome Management: Hemorrhoids Surgical Management

Sclerotherapy & Ligation

Cryosurgery & Laser Hemorrhoidectomy

Nursing Management Promote Healing,

Prevent Complications, & Relieve Pain

Medical Management Prevent complications Relieve pain

Complications

Bleeding Thrombosis Hemorrhoidal strangulation Iron deficiency anemia Severe pain, extreme edema and

inflammation when strangulated

Documents

Management of Clients with Intestinal Disorders NRS 108 SPRING 2008 LOLA OYEDELE MSN,RN,CTN MAJUVY SULSE MSN, RN, CCRN