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Medical Surgical
Care of the Patient with a
Gastrointestinal Disorder
Edited by M. Myers
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
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Digestive system
◦ Organs and their functions
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Mouth: Beginning of digestion
Teeth: Bite, crush, and grind food
Salivary glands: Secrete saliva
Esophagus: Moves food from mouth to stomach
Stomach: Churn and mix contents with gastric juices
Small intestine: Most digestion occurs here
Large intestine: Forms and expels feces
Rectum: Expels feces
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 2
(From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.)
Location of digestive organs.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 3
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Accessory organs of digestion
◦ Organs and their functions
 Liver: Produces bile; stores it in the gallbladder
 Pancreas: Produces pancreatic juice
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Regulation of food intake
◦ Hypothalamus
 One center stimulates eating and another signals to
stop eating
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 4
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Upper GI series
Gastric analysis
Esophagogastroduodenoscopy (EGD)
Barium swallow
Bernstein test
Stool for occult blood
Sigmoidoscopy
Barium enema
Colonoscopy
Stool culture and sensitivity; stool for ova and
parasites
Flat plate of the abdomen
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 5
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Dental plaque and caries
◦ Etiology/pathophysiology
 Erosive process that results from the action of bacteria
on carbohydrates in the mouth, which produces acids
that dissolve tooth enamel
◦ Medical management/nursing interventions
 Remove affected area and replace with dental material
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 6
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Candidiasis
◦ Etiology/pathophysiology
 Infection caused by a species of Candida, usually
Candida albicans
 Fungus normally present in the mouth, intestine, and
vagina, and on the skin
 Also referred to as thrush and moniliasis
◦ Clinical manifestations/assessment
 Small white patches on the mucous membrane of the
mouth
 Thick white discharge from the vagina
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 7
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Candidiasis (continued)
◦ Medical management/nursing interventions
 Pharmacological management
 Nystatin
 Ketoconazole oral tablets
 Half-strength hydrogen peroxide/saline mouthwash
 Meticulous handwashing
 Comfort measures
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 8
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Carcinoma of the oral cavity
◦ Etiology/pathophysiology
 Malignant lesions on the lips, oral cavity, tongue, or
pharynx
 Usually squamous cell epitheliomas
◦ Clinical manifestations/assessment
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Leukoplakia
Roughened area on the tongue
Difficulty chewing, swallowing, or speaking
Edema, numbness, or loss of feeling in the mouth
Earache, face ache, and toothache
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Slide 9
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Carcinoma of the oral cavity (continued)
◦ Diagnostic tests
 Indirect laryngoscopy
 Excisional biopsy
◦ Medical management/nursing interventions
 Stage I: Surgery or radiation
 Stage II & III: Both surgery and radiation
 Stage IV: Palliative
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 10
Esophagus
• Tracheoesophageal fistula
• Newborn: copious saliva
choking, coughing
cyanosis on food intake
• Most common form: lower part of
esophagus joins the trachea (near the
bifurcation)
Esophagus
• Tracheoesophageal fistula
• Newborn: copious saliva
choking, coughing
cyanosis on food intake
• Most common form: lower part of
esophagus joins the trachea (near the
bifurcation)
Esophageal diverticula
• Outpocketing of the esophageal wall
• False( pulsion) type: the mucosa herniates into
the muscular layer
• True (traction) type: outpocketing of all the
layers
• 3 common locations:
• 1. above UES (Zenker diverticulum)
• 2. midpoint of the esophagus
• 3. above LES (Epiphrenic diverticulum)
Zenker’s diverticulum
Epiphrenic diverticulum
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Gastroesophageal reflux disease (continued)
◦ Diagnostic tests
 Esophageal motility and Bernstein tests
 Barium swallow
 Endoscopy
◦ Medical management/nursing interventions
 Pharmacological management
 Antacids or acid-blocking medications
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Dietary recommendations
Lifestyle recommendations
Comfort measures
Surgery
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 16
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Gastroesophageal reflux disease
◦ Etiology/pathophysiology
 Backward flow of stomach acid into the esophagus
◦ Clinical manifestations/assessment
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Heartburn (pyrosis) 20 min to 2 hours after eating
Regurgitation
Dysphagia or odynophagia
Eructation
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Slide 17
Gastroesophageal reflux
• Reflux of gastric contents into the
esophagus
• Heartburn, substernal pain, burning
sensation
• Predisposing factors: alcohol, smoking,
pregnancy
• May lead to: esophagitis, strictures, Barrett
esophagus
Barrett esophagus
• Normal epithelium: squamous type
• Barrett: becomes columnar with many
Goblet cells
• Precursor for adenocarcinoma of the
esophagus
Barrett esophagus
Barrett esophagus
Cancer of the esophagus
• Most frequent type: squamous cell
carcinoma
• Dysphagia, weight loss, anorexia
• Upper and middle thirds of the esophagus
• Adenocarcinoma type : lower third of the
esophagus
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Carcinoma of the esophagus
◦ Etiology/pathophysiology
 Malignant epithelial neoplasm that has invaded the
esophagus
 90% are squamous cell carcinoma associated with alcohol
intake and tobacco use
 6% are adenocarcinomas associated with reflux esophagitis
◦ Clinical manifestations/assessment
 Progressive dysphagia over a 6-month period
 Sensation of food sticking in throat
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Slide 23
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Carcinoma of the esophagus (continued)
◦ Medical management/nursing interventions
 Radiation: May be curative or palliative
 Surgery: May be palliative, increase longevity, or
curative
 Types of surgical procedures
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Esophagogastrectomy
Esophagogastrostomy
Esophagoenterostomy
Gastrostomy
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 24
Cancer of the esophagus
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Achalasia
◦ Etiology/pathophysiology
 Cardiac sphincter of the stomach cannot relax
 Possible causes: Nerve degeneration, esophageal
dilation, and hypertrophy
◦ Clinical manifestations/assessment
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Dysphagia
Regurgitation of food
Substernal chest pain
Loss of weight; weakness
Poor skin turgor
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 26
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Achalasia (continued)
◦ Diagnostic tests
 Radiologic studies; esophagoscopy
◦ Medical management/nursing interventions
 Pharmacological management
 Anticholinergics, nitrates, and calcium channel blockers
 Dilation of cardiac sphincter
 Surgery
 Cardiomyectomy
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Slide 27
Gastritis
• Acute gastritis
• Causes:
NSAIDS
smoking
alcholic drinks
burns :
Curlings ulcer
Cushings ulcer
• Chronic gastritis
• Chronic inflammation,
atrophy of the
mucosa
• Helicobacter pylori
gastritis: most
common form
• Increases risk of
gastric cancer
Acute Gastritis
Peptic ulcers
• Common locations:
lesser curvature
antrum
prepyloric areas
• Causes: H.pylori infection
bile-induced gastritis
• Not a precursor lesion of carcinoma of the
stomach
Benign Gastric Ulcers
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Acute gastritis
◦ Etiology/pathophysiology
 Inflammation of the lining of the stomach
 May be associated with alcoholism, smoking, and
stressful physical problems
◦ Clinical manifestations/assessment
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Fever; headache
Epigastric pain; nausea and vomiting
Coating of the tongue
Loss of appetite
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 32
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Acute gastritis (continued)
◦ Diagnostic tests
 Stool for occult blood; WBC; electrolytes
◦ Medical management/nursing interventions
 Pharmacological management
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Antiemetics
Antacids
Antibiotics
IV fluids
 NG tube and administration of blood, if bleeding
 NPO until signs and symptoms subside
 Monitor intake and output
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 33
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Gastric ulcers and duodenal ulcers
◦ Ulcerations of the mucous membrane or deeper
structures of the GI tract
◦ Most commonly occur in the stomach and
duodenum
◦ Result of acid and pepsin imbalances
◦ H. pylori
 Bacterium found in 70% of patients with gastric ulcers
and 95% of patients with duodenal ulcers
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 34
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Gastric ulcers (continued)
◦ Etiology/pathophysiology
 Gastric mucosa are damaged, acid is secreted, mucosal
erosion occurs, and an ulcer develops
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Duodenal ulcers (continued)
◦ Etiology/pathophysiology
 Excessive production or release of gastrin, increased
sensitivity to gastrin, or decreased ability to buffer the
acid secretions
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 35
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Gastric and duodenal ulcers (continued)
◦ Clinical manifestations/assessment
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Pain: Dull, burning, boring, or gnawing, epigastric
Dyspepsia
Hematemesis
Melena
◦ Diagnostic tests
 Esophagogastroduodenoscopy (EGD)
 Breath test for H. pylori
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 36
(from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St.
Louis: Mosby.)
Fiberoptic endoscopy of the stomach.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 37
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Gastric and duodenal ulcers (continued)
◦ Medical management/nursing interventions
 Pharmacological management
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Antacids
Histamine H2 receptor blockers
Proton pump inhibitor
Mucosal healing agents
Antibiotics
 Dietary recommendations
 High in fat and carbohydrates; low in protein and milk
products; small frequent meals; limit coffee, tobacco,
alcohol, and aspirin use
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 38
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Gastric and duodenal ulcers (continued)
◦ Medical management/nursing interventions
 Surgery
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Antrectomy
Gastroduodenostomy (Billroth I)
Gastrojejunostomy (Billroth II)
Total gastrectomy
Vagotomy
Pyloroplasty
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Slide 39
Types of gastric resections with anastomoses.
A, Billroth I. B, Billroth II.
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Slide 40
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Gastric and duodenal ulcers (continued)
◦ Complications after gastric surgery
 Dumping syndrome
 Pernicious anemia
 Iron deficiency anemia
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 41
Cancer of the Stomach
• Common: more than 50 years old, men, Blood
group A
• Predisposing factors:
H. pylori infection
Nitrosamines
excessive salt intake
low fresh fruits, vegetables diet
achlorhydia
chronic gastritis
Cancer of the stomach
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Most common type: adenocarcinoma
Rare in the fundus
Aggressive spread to adjacent organs
Virchow node: large supraclavicular node
Krukenberg tumors: bilateral, enlarged ovaries,
“signet ring” cells
• Two types:
• 1. intestinal type: fungating mass; ulcer with
irregular necrotic base and firm, raised margins
• 2. infiltrating or diffuse type: linitis plastica
Signet ring cells
Cancer of the stomach
Krukenberg tumors
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Cancer of the stomach
◦ Etiology/pathophysiology
 Most commonly adenocarcinoma
 Primary location is the pyloric area
 Risk factors:
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History of polyps
Pernicious anemia
Hypochlorhydria
Gastrectomy; chronic gastritis; gastric ulcer
Diet high in salt, preservatives, and carbohydrates
Diet low in fresh fruits and vegetables
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Slide 47
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Cancer of the stomach (continued)
◦ Clinical manifestations/assessment
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Early stages may be asymptomatic
Vague epigastric discomfort or indigestion
Postprandial fullness
Ulcer-like pain that does not respond to therapy
Anorexia; weight loss
Weakness
Blood in stools; hematemesis
Vomiting after fluids and meals
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 48
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Cancer of the stomach (continued)
◦ Diagnostic tests
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GI series
Endoscopic/gastroscopic examination
Stool for occult blood
RBC, hemoglobin, and hematocrit
◦ Medical management/nursing interventions
 Surgery
 Partial or total gastric resection
 Chemotherapy and/or radiation
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Slide 49
Congenital pyloric stenosis
• Hypertrophy of the
circular muscle layer
of the pylorus
• Projectile vomiting in
1st 2 weeks of life
• Palpable mass
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Infection
◦ Etiology/pathophysiology
 Invasion of the alimentary canal by pathogenic
microorganisms
 Most commonly enters through the mouth in food or
water
 Person-to-person contact
 Fecal-oral transmission
 Long-term antibiotic therapy can cause an overgrowth
of the normal intestinal flora
(C. difficile)
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Slide 51
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Infection (continued)
◦ Clinical manifestations/assessment
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Diarrhea
Rectal urgency
Tenesmus
Nausea and vomiting
Abdominal cramping
Fever
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Slide 52
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Infection (continued)
◦ Diagnostic tests
 Stool culture
◦ Medical management/nursing interventions
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Antibiotics
Fluid and electrolyte replacement
Kaopectate
Pepto-Bismol
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Slide 53
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Irritable bowel syndrome
◦ Etiology/pathophysiology
 Episodes of alteration in bowel function
 Spastic and uncoordinated muscle contractions of the
colon
◦ Clinical manifestations/assessment
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Abdominal pain
Frequent bowel movements
Sense of incomplete evacuation
Flatulence, constipation, and/or diarrhea
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 54
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Irritable bowel syndrome (continued)
◦ Diagnostic tests
 History and physical examination
◦ Medical management/nursing interventions
 Pharmacological management
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Anticholinergics
Milk of magnesia
Mineral oil
Opioids
Antianxiety agents
 Dietary recommendations
 Bulking agents
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Slide 55
Crohn disease
• Chronic inflammatory disease of ALL the layers
of the intestinal wall with thickening; narrow
lumen
• 20 – 30 year old, Jewish descent
• Small intestine and colon
• May lead to carcinoma
• Skip lesions
• Cobblestone appearance
• Fistulas
• Noncaseating granulomas
Crohn’s disease
• Presents as:
abdominal pain
diarrhea
fever
malabsorption
obstruction
fistula to bladder, vagina, skin
Crohn’s disease
Meckel’s diverticulum
• Most common congenital abnormality of
the small intestine
• Remnant of the vitelline duct in the distal
small bowel
• Peptic ulceration, bleeding, perforation
• Intussusception
• volvulus
Celiac disease
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Malabsorption disease
Sensitivity to gluten products
Blunting of the intestinal villi
Diarrhea:bulky, frothy, foul-smelling
Weight loss, failure to thrive, weakness
Treatment: gluten-free diet
Cancer of the small intestine
• Mostly adenocarcinoma
• Appendix: carcinoid type; when it metastasizes
to the liver  carcinoid syndrome:
• Flushed skin
• Watery diarrhea, abdominal cramps
• Bronchospasm
• Valvular lesions of the heart
Colon
Ulcerative colitis
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Ulcers in the large intestine or entire colon
Pseudopolyps
Crypt abscesses
Chronic diarrhea
Most frequent presentation: rectal bleeding
Complications:
Toxic megacolon
Colon perforation
Colon cancer
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Ulcerative colitis
◦ Etiology/pathophysiology
 Ulceration of the mucosa and submucosa of the colon
 Tiny abscesses form that produce purulent drainage,
slough the mucosa, and ulcerations occur
◦ Clinical manifestations/assessment
 Diarrhea—pus and blood; 15 to 20 stools per day
 Abdominal cramping
 Involuntary leakage of stool
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Slide 65
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Ulcerative colitis (continued)
◦ Diagnostic tests
 Barium studies, colonoscopy, stool for occult blood
◦ Medical management/nursing interventions
 Pharmacological management
 Azulfidine, Dipentum, Rowasa, corticosteroids, Imodium
 Dietary recommendations: No milk products or spicy
foods; high-protein, high-calorie; total parenteral
nutrition
 Stress control
 Assist patient to find coping mechanisms
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Slide 66
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Ulcerative colitis (continued)
◦ Medical management/nursing interventions
 Surgical interventions
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Colon resection
Ileostomy
Ileoanal anastomosis
Proctocolectomy
Kock pouch
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Slide 67
Kock pouch (Kock continent ileostomy).
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Slide 68
Ileostomy with absence of resected bowel.
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Slide 69
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Crohn’s disease
◦ Etiology/pathophysiology
 Inflammation, fibrosis, scarring, and thickening of the
bowel wall
◦ Clinical manifestations/assessment
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Weakness; loss of appetite
Diarrhea: 3 to 4 daily; contain mucus and pus
Right lower abdominal pain
Steatorrhea
Anal fissures and/or fistulas
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Slide 70
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Crohn’s disease (continued)
◦ Medical management/nursing interventions
 Pharmacological management
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Corticosteroids
Azulfidine
Antibiotics
Antidiarrheals; antispasmodics
Enteric-coated fish oil capsules
B12 replacement
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 71
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Crohn’s disease (continued)
◦ Medical management/nursing interventions
 Dietary recommendations
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High-protein
Elemental
Hyperalimentation
Avoid
 Lactose-containing foods, brassica vegetables, caffeine,
beer, monosodium glutamate, highly seasoned foods,
carbonated beverages, fatty foods
 Surgery
 Segmental resection of diseased bowel
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Slide 72
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Appendicitis
◦ Etiology/pathophysiology
 Inflammation of the vermiform appendix
 Lumen of the appendix becomes obstructed, the
E. coli multiplies, and an infection develops
◦ Clinical manifestations/assessment
 Rebound tenderness over the right lower quadrant of
the abdomen (McBurney’s point)
 Vomiting
 Low-grade fever
 Elevated WBC
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Slide 73
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Appendicitis (continued)
◦ Diagnostic tests
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WBC
Roentgenogram
Ultrasound
Laparoscopy
◦ Medical management/nursing interventions
 Appendectomy
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Slide 74
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Diverticular disease
◦ Etiology/pathophysiology
 Diverticulosis
 Pouch-like herniations through the muscular layer of the
colon
 Diverticulitis
 Inflammation of one or more diverticula
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Slide 75
Diverticulosis.
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Slide 76
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Diverticular disease (continued)
◦ Clinical manifestations/assessment
 Diverticulosis
 May have few, if any, symptoms
 Constipation, diarrhea, and/or flatulence
 Pain in the left lower quadrant
 Diverticulitis
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Mild to severe pain in the left lower quadrant
Elevated WBC; low-grade fever
Abdominal distention
Vomiting
Blood in stool
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Slide 77
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Diverticular disease (continued)
◦ Medical management/nursing interventions
 Diverticulosis with muscular atrophy
 Low-residue diet; stool softeners
 Bed rest
 Diverticulosis with increased intracolonic pressure and
muscle thickening
 High-fiber diet
 Sulfa drugs
 Antibiotics; analgesics
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Slide 78
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Diverticular disease (continued)
◦ Medical management/nursing interventions
(continued)
 Surgery
 Hartmann’s pouch
 Double-barrel transverse colostomy
 Transverse loop colostomy
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Slide 79
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Peritonitis
◦ Etiology/pathophysiology
 Inflammation of the abdominal peritoneum
 Bacterial contamination of the peritoneal cavity from
fecal matter or chemical irritation
◦ Clinical manifestations/assessment
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Severe abdominal pain; nausea and vomiting
Abdomen is tympanic; absence of bowel sounds
Chills; weakness
Weak rapid pulse; fever; hypotension
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 80

Peritonitis (continued)
◦ Diagnostic tests
 Flat plate of the abdomen
 CBE
◦ Medical management/nursing interventions
 Pharmacological management
 Parenteral antibiotics
 Analgesics
 IV fluids
 Position patient in semi-Fowler’s position
 Surgery
 Repair cause of fecal contamination
 Removal of chemical irritant
 NG tube to prevent GI distention
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 81

External hernias
◦ Etiology/pathophysiology
 Congenital or acquired weakness of the abdominal wall
or postoperative defect
 Abdominal
 Femoral or inguinal
 Umbilical
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Slide 82

External hernias (continued)
◦ Clinical manifestations/assessment
 Protruding mass or bulge around the umbilicus, in the
inguinal area, or near an incision
 Incarceration
 Strangulation
◦ Diagnostic tests
 Radiographs
 Palpation
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 83

External hernias (continued)
◦ Medical management/nursing interventions
 If no discomfort, hernia is left unrepaired, unless it
becomes strangulated or obstruction occurs
 Truss
 Surgery
 Synthetic mesh is applied to weakened area of the
abdominal wall
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 84

Hiatal hernia
◦ Etiology/pathophysiology
 Protrusion of the stomach and other abdominal viscera
through an opening in the membrane or tissue of the
diaphragm
 Contributing factors: obesity, trauma, aging
◦ Clinical manifestations/assessment
 Most people display few, if any, symptoms
 Gastroesophageal reflux
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 85
Hiatal hernia. A, Sliding hernia. B, Rolling hernia.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 86

Hiatal hernia (continued)
◦ Medical management/nursing interventions
 Head of bed should be slightly elevated when lying
down
 Surgery
 Posterior gastropexy
 Transabdominal fundoplication (Nissen)
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 87

Intestinal obstruction
◦ Etiology/pathophysiology




Intestinal contents cannot pass through the GI tract
Partial or complete
Mechanical
Non-mechanical
◦ Clinical manifestations/assessment
 Vomiting; dehydration
 Abdominal tenderness and distention
 Constipation
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 88
Intestinal obstructions. A, Adhesions. B, Volvulus.
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 89

Intestinal obstruction (continued)
◦ Diagnostic tests
 Radiographic examinations
 BUN, sodium, potassium, hemoglobin, and hematocrit
◦ Medical management/nursing interventions
 Evacuation of intestine
 NG tube to decompress the bowel
 Nasointestinal tube with mercury weight
 Surgery
 Required for mechanical obstructions
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 90

Colorectal cancer
◦ Etiology/pathophysiology
 Malignant neoplasm that invades the epithelium and
surrounding tissue of the colon and rectum
 Second most prevalent internal cancer in the United
States
◦ Clinical manifestations/assessment




Change in bowel habits; rectal bleeding
Abdominal pain, distention, and/or ascites
Nausea
Cachexia
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 91

Cancer of the colon (continued)
◦ Diagnostic tests
 Proctosigmoidoscopy with biopsy
 Colonoscopy
 Stool for occult blood
◦ Medical management/nursing interventions
 Radiation
 Chemotherapy
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 92

Cancer of the colon (continued)
◦ Medical management/nursing interventions
(continued)
 Surgery
 Obstruction
 One-stage or two-stage resection
 Two-stage resection
 Colorectal cancer
 Right or left hemicolectomy
 Anterior rectosigmoid resection
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 93

Hemorrhoids
◦ Etiology/pathophysiology
 Varicosities (dilated veins)
 External or internal
 Contributing factors
 Straining with defecation, diarrhea, pregnancy, CHF, portal
hypertension, prolonged sitting and standing
◦ Clinical manifestations/assessment




Varicosities in rectal area
Bright red bleeding with defecation
Pruritus
Severe pain when thrombosed
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 94

Hemorrhoids (continued)
◦ Medical management/nursing interventions
 Pharmacological management
 Bulk stool softeners
 Hydrocortisone cream
 Topical analgesics






Sitz baths
Ligation
Sclerotherapy; cryotherapy
Infrared photocoagulation
Laser excision
Hemorrhoidectomy
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 95

Anal fissure
◦ Linear ulceration or laceration of the skin of the
anus
◦ Usually caused by trauma
◦ Lesions usually heal spontaneously
◦ May be excised surgically

Anal fistula
◦
◦
◦
◦
Abnormal opening on the surface near the anus
Usually from a local abscess
Common in Crohn’s disease
Treated by a fistulectomy or fistulotomy
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 96

Nursing diagnoses
 Activity intolerance
 Anxiety
 Body image,
disturbed
 Constipation
 Coping, ineffective
 Diarrhea
 Fear
 Fluid volume,
deficient, risk for
 Home management, impaired
 Management of therapeutic
regimen, ineffective
 Nutrition, imbalanced: less
than body requirements
 Pain, chronic/acute
 Skin integrity, risk for impaired
 Sleep pattern, disturbed
 Social isolation
 Tissue perfusion, ineffective
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 97

Fecal incontinence
◦ Potential causes
◦ Medical management/nursing interventions




Biofeedback training
Bowel training
Patient education
Dietary recommendations
Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 98
Small Intestine
Peptic ulcer of the Small intestine
• Always associated with increased secretion of
gastric acid and pepsin
• High risk in H. pylori infection
• Other predisposing factors:
aspirin, NSAIDS
smoking
Zollinger-Ellison syndrome: gastrin-secreting
tumor of the pancreas
primary hyperparathyroidism
• Not a precursor of malignancy
Colon Polyps
• Elevation of he intestinal surface
• Peutz-Jeghers polyps: polyps in the colon
+ dark spots on lips, hands, genitalia
• Villous adenomas: highest potential of the
adenomatous polyps to become malignant
• Familial polyposis: malignant changes in
100% of cases
Adenocarcinoma of the colon
• 60 to 70 years old
• Cancer marker: CEA
• Predisposing factors:
adenomatous polyps
familial polypposis
4x higher in relatives with colon cancer
low fiber, high animal fat diet
• Cancer of the rectosigmoid: annular
enlargement; obstruction
• Cancer of the right colon: late obstruction;
chronic blood loss; iron deficiency anemia