Download Smeltzer Textbook of Medical Surgical Nursing

Chapter 38
Management of Patients With
Intestinal and Rectal Disorders
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Constipation
• Abnormal infrequency or irregularity of defecation; any
variation from normal habits may be a problem.
• Causes include medications, chronic laxative use,
weakness, immobility, fatigue, inability to increase intraabdominal pressure, diet, ignoring urge to defecate, and
lack of regular exercise.
• Increased risk in older age.
• Perceived constipation: a subjective problem in which the
person’s elimination pattern is not consistent with what
he or she believes is normal.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Manifestations
• Fewer than 3 BMs per week
• Abdominal distention
• Decreased appetite
• Headache
• Fatigue
• Indigestion
• A sensation of incomplete evacuation
• Straining at stool
• Elimination of small-volume, hard, dry stools
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Complications
• Hypertension
• Fecal impaction
• Hemorrhoids
• Fissures
• Megacolon
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Patient Learning Needs
• See Chart 38-1
• Normal variations of bowel patterns
• Establishment of normal pattern
• Dietary fiber and fluid intake
• Responding to the urge to defecate
• Exercise and activity
• Laxative use (see Table 38-1)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions to prevent and relieve
constipation
•
Adequate fluid intake.
•
High-fiber diet.
•
Establish regular pattern of defecation
•
Respond immediately to the urge to defecate.
•
Minimize stress. – Sympathetic response.
•
Promote adequate activity and exercise.
•
Assume sitting or squatting position.
•
Administer laxatives as ordered
•
TYPES:
•
Chemical irritants- provide chemical stimulation to
intestinal wall- increase peristalsis . Ex. Dulcolax, castor oil,
senokot (senna)
•
Stool lubricants – mineral oil
•
Stool softeners – Colace (Na Docussate)
•
Bulk formers – Metamucil
•
Osmotic agents – Milk of magnesia, duphalac
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
TYPES OF LAXATIVES
TYPE
ACTION
EXAMPLES
BULK-FORMING
INCREASES THE FLUID, GASEOUS, OR
SOLID BULK IN THE INTESTINES
PSYLLIUM HYDROPHILIC
MUCILLOID (METAMUCIL),
METHYLCELLULOSE
(CITRUCEL)
EMOLIENT/STOOL
SOFTENER
SOFTENS AND DELAYS THE DRYING OF
THE FECES; PERMITS FATS AND WATER
TO PENETRATE FECES
DOCUSATE SODIUM (COLACE)
STIMULANT/
IRRITANT
IRRITATES THE INTESTINAL MUCOSA OR
STIMULATES NERVE ENDINGS IN THE
WALL OF THE INTESTINE, CAUSING
RAPID PROPULSION OF THE CONTENTS
BISACODYL (DULCOLAX,
CORRECTOL), SENNA
(SENOKOT, EX-LAX), CASCARA,
CASTOR OIL
LUBRICANT
LUBRICATES THE FECES IN THE COLON
MINERAL OIL (HALEY’S M-O)
SALINE/OSMOTIC
DRAWS WATER INTO THE INTESTINE BY
OSMOSIS, DISTENDS THE BOWEL, AND
STIMULATES PERISTALSIS
EPSOM SALTS, MAGNESIUM
HYDROXIDE (MILK OF
MAGNESIA), MAGNESIUM
CITRATE, SODIUM PHOSPATE
(FLEET PHOSPODA)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
TEACHING ABOUT MEDICATIONS
Cathartics and Laxatives
 Cathartics are drugs that induce defecation. They can
have strong, purgative effect. A laxative is mild in
comparison to a cathartic, and it produces soft or liquid
stools that are sometimes accompanied by abdominal
cramps.
 Cathartics: Castor oil, cascara, phenolphthalein and
bisacodyl.
 Laxatives are contraindicated in the client who has
nausea, cramps. Colic, vomiting, or undiagnosed
abdominal pain. Clients need to be informed about the
dangers of laxative use.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
What is an example of a laxative osmotic agent?
A. Bisacodyl (Dulcolax)
B. Dioctyl sodium sulfosuccinate (Colace)
C. Magnesium hydroxide (Milk of Magnesia)
D. Polyethylene glycol and electrolytes (Colyte)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
D
Polyethylene glycol and electrolytes (Colyte) are an
osmotic agent. Bisacodyl (Dulcolax) is a stimulant
laxative. Dioctyl sodium sulfosuccinate (Colace) is a fecal
softener. Magnesium hydroxide (Milk of Magnesia) is a
saline agent.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diarrhea
• Increased frequency of bowel movements (more than 3
per day), increase amount of stool (more than 200 g per
day), and altered consistency (i.e., looseness) of stool.
• Usually associated with urgency, perianal discomfort,
incontinence, or a combination of these factors.
• May be acute or chronic.
• Causes include infections, medications, tube feeding
formulas, metabolic and endocrine disorders, and various
disease processes.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Manifestations
• Increased frequency and fluid content of stools
• Abdominal cramps
• Distention
• Borborygmus
• Painful spasmodic contractions of the anus
• Tenesmus
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Complications
• Fluid and electrolyte imbalances
• Dehydration
• Cardiac dysrhythmias
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Patient Learning Needs
• Recognition of need for medical treatment
• Rest
• Diet and fluid intake
• Avoid irritating foods—caffeine, carbonated beverages, very
hot and cold foods
• Perianal skin care
• Medications
• May need to avoid milk, fat, whole grains, fresh fruit, and
vegetables
• Lactose intolerance (see Chart 38-2)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions to relieve diarrhea
• Monitor I & O. Assess for:

urine- frequency, color, consistency and volume

Stools

Vomitus
• Replace fluid and electrolyte losses.
• Provide good perianal care
• Promote rest.
• Diet:

Small amounts of bland foods

Low fiber diet

BRAT

Avoid excessive hot or cold fluids.

Potassium rich foods and fluid.
• Antidiarrheal medications.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Dietary Management
• Fluid replacement
 Oresol
• Avoid food in the first 24 hours to provide bowel rest, after
that time, frequent small feedings
• Milk are temporary withheld
• Avoid raw fruits and vegetables, fried foods, spices coffee.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Care
• Directed toward identifying
the cause, relieving
symptoms, preventing
complications and if
infectious, preventing the
spread of infection to others.
• RISK FOR FLUID VOLUME
DEFICIT
•
RECORD I & O
•
Monitor v/s and record
including orthostatic
hypotension
•
Provide fluid and
electrolyte replacement
solutions as indicatedincrease OFI as tolerated
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
RISK FOR IMPAIRED SKIN INTEGRITY
 Provide good skin care
 Assist in cleaning the perianal area
 Apply protective ointment to the perianal area
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
What is IBS?
• Also known as spastic colon, spastic colitis, mucous
colitis and irritable colon
• Most common functional disorder of the GIT
• Causes increased motility of the small or large intestine
• Affects the intestine’s structure, but cause is unknown
• Does not lead to or cause ulcerative colitis or cancer
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Signs and Symptoms
 Causes alternately tense and flaccid bowel segments
 Symptoms vary in intensity and pattern
 Aggravated by foods, alcohol ingestion, stress and fatigue
 Resulting symptoms include:
 Nausea
 Abdominal pain
 Cramps
 Flatulence (gas)
 Altered bowel function (constipation or diarrhea)
 Hypersecretion of colonic mucus
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnosis
 Upper GI series
 Barium enema
 Colonoscopy appropriate for
older adults
 Tests that eliminate other
pathologies with similar
symptoms
 Nursing Alert!
 Rectal Bleeding and fever
are not associated
symptoms of IBS. The
person with these
symptoms should report to
a physician for evaluation.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Treatment
 Lifestyle changes
 Counseling
 Biofeedback and relaxation training
 High-fiber diet and agents that add
bulk like Metamucil and Effersyllium
 Adequate oral fluids and regular
meal patterns
 Limitation of dairy products if lactose
intolerant
 Medications for symptomatic relief
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Types of Medications
 Sedatives or tranquilizers such as alprazolam (Xanax)
 Help quiet the bowel’s activity
 Provide relaxation
 Antispasmodic agents like dicylclomine hydrochloride (Bentyl)
and hyoscyamine (Donnatal)
 Relieve pain and cramping symptoms
 Common side effects:
Dry mouth
Blurred vision
dizziness
 Antidiarrheal agents like loperamide (Imodium) to maintain
normal activity
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
•Nursing
Consistency
Considerations
• Follow prescribed treatment plan.
• Keep a log or diary to track progress or identify
changes.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Malabsorption
• The inability of the digestive system to absorb one or
more of the major vitamins, minerals, and nutrients
• Conditions (see Table 38-2)
– Mucosal (transport) disorders
– Infectious disease
– Luminal disorders
– Postoperative malabsorption
– Disorders that cause malabsorption of specific
nutrients
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diverticular Disease
• Diverticulum: sac-like herniations of the lining of the
bowel that extend through a defect in the muscle layer
• May occur anywhere in the intestine but are most
common in the sigmoid colon
• Diverticulosis: multiple diverticula without inflammation
• Diverticulitis: infection and inflammation of diverticula
• Diverticular disease increases with age and is associated
with a low-fiber diet
• Diagnosis is usually by colonoscopy
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical
manifestations
• Left lower Quadrant
pain
• Flatulence
• Bleeding per rectum
Diagnostic Test
• If no active
inflammation,
COLONOSCOPY and
Barium Enema
• nausea and vomiting
• CT scan is the
procedure of choice!
• Fever
• Abdominal X-ray
• Palpable, tender rectal
mass
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Diverticulitis—Assessment
• Patients may have chronic constipation preceding
development of diverticulosis, frequently asymptomatic
but may include bowel irregularities, nausea, anorexia,
bloating, and abdominal distention.
• With diverticulitis, symptoms include mild or severe pain
in lower left quadrant, nausea, vomiting, fever, chills,
and leukocytosis.
• Ask regarding the onset and duration of pain, and past
and present elimination patterns.
• Nutrition and dietary patterns including fiber intake.
• Inspect stool and monitor for symptoms potential
complications.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Diverticulitis—Diagnoses
• Constipation
• Acute pain
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Collaborative Problems/Potential
Complications
• Perforation
• Peritonitis
• Abscess formation
• Bleeding
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Diverticulitis—Planning
• Major goals may include attainment and maintenance of
normal elimination patterns, pain, relief, and absence of
complications.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
The most common site for diverticulitis is the ileum.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
False
The most common site for diverticulitis is not the ileum.
The most common site for diverticulitis is the sigmoid.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Maintaining Normal Elimination Pattern
• Encourage fluid intake of at least 2 L/d
• Soft foods with increased fiber, such as cooked
vegetables
• Individualized exercise program
• Bulk laxatives (psyllium) and stool softeners
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Summary of interventions
• Maintain NPO during acute phase
• Provide bed rest
• Administer antibiotics, analgesics like meperidine (morphine is
not used) and anti-spasmodics
• Monitor for potential complications like perforation,
hemorrhage and fistula
• Increase fluid intake
• 6. Avoid gas-forming foods or HIGH-roughage foods containing
seeds, nuts to avoid trapping
• 7. introduce soft, high fiber foods ONLY after the inflammation
subsides
• 8. Instruct to avoid activities that increase intra-abdominal
pressure
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Inflammatory Bowel Disease (IBD)
• Crohn’s disease (regional enteritis)
• Ulcerative colitis
• See Table 38-4
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
Abdominal pain and constipation are common clinical
manifestations of Crohn’s disease.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
False
Abdominal pain and diarrhea are common clinical
manifestations of Crohn’s disease.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Inflammatory Bowel Disease—
Assessment
• Health history to identify onset, duration and
characteristics of pain, diarrhea, urgency, tenesmus,
nausea, anorexia, weight loss, bleeding, and family
history
• Discuss dietary patterns, alcohol, caffeine, and nicotine
use
• Assess bowel elimination patterns and stool
• Abdominal assessment
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Crohn’s Disease
• CROHN’S DISEASE Also called Regional Enteritis An
inflammatory disease of the GIT affecting usually the
small intestine
• ETIOLOGY: unknown The terminal ileum thickens, with
scarring, ulcerations, abscess formation and narrowing of
the lumen
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical manifestations of Chrohn’s
Disease
• Fever
• Abdominal distention
• Diarrhea
• Colicky abdominal pain
• Anorexia/N/V
• Weight loss
• Anemia
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
ULCERATIVE COLITIS
• Ulcerative and inflammatory condition of the GIT usually
affecting the large intestine.
• The colon becomes edematous and develops bleeding
ulcerations.
• Scarring develops overtime with impaired water
absorption and loss of elasticity
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical manifestations of Ulcerative
colitis
• 1. Anorexia
• 2. Weight loss
• 3. Fever
• 4. SEVERE diarrhea with Rectal bleeding
• 5. Anemia
• 6. Dehydration
• 7. Abdominal pain and cramping
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Inflammatory Bowel Disease—
Diagnoses
• Diarrhea
• Acute pain
• Deficient fluid
• Imbalanced nutrition
• Activity intolerance
• Anxiety
• Ineffective coping
• Risk for impaired skin integrity
• Risk for ineffective therapeutic regimen management
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Collaborative Problems/Potential
Complications
• Electrolyte imbalance
• Cardiac dysrhythmias
• GI bleeding with fluid loss
• Perforation of the bowel
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with Inflammatory Bowel Disease—
Planning
• Major goals may include attainment of normal bowel
elimination patterns, relief of abdominal pain and
cramping, prevention of fluid deficit, maintenance of
optimal nutrition and weight, avoidance of fatigue,
reduction of anxiety, promotion of effective coping,
absence of skin breakdown, increased knowledge of
disease process and therapeutic regimen, and avoidance
of complications.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Maintaining Normal Elimination Pattern
• Identify relationship between diarrhea and food,
activities, or emotional stressors.
• Provide ready access to bathroom/commode.
• Encourage bed rest to reduce peristalsis.
• Administer medications as prescribed.
• Record frequency, consistency, character, and amounts
of stools.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Other Interventions
• Assessment and treatment of pain/discomfort,
anticholinergic medications prior to meals, analgesics,
positioning, diversional activities, and prevention of
fatigue
• Fluid deficit, I&O, daily weight, assessment of symptoms
of dehydration/fluid loss, encourage oral intake,
measures to decrease diarrhea
• Optimal nutrition; elemental feedings that are high in
protein and low residue or PN may be needed
• Reduce anxiety; calm manner, allow patient to express
feelings, listening, patient teaching
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Summary of Interventions
• Maintain NPO during the active phase
• Monitor for complications like severe bleeding, dehydration,
electrolyte imbalance
• Monitor bowel sounds, stool and blood studies
• Restrict activities
• Administer IVF, electrolytes and TPN if prescribed
• Instruct the patient to AVOID gas-forming foods, MILK
products and foods such as whole grains, nuts, RAW fruits
and vegetables especially SPINACH, pepper, alcohol and
caffeine
• 7. Diet progression- clear liquid
diet
LOW residue, high protein
• 8. Administer drugs- anti-inflammatory, antibiotics, steroids,
bulk-forming agents
and vitamin/iron supplements
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Patient Teaching
• See Chart 38-3
• Understanding of disease process
• Nutrition/diet
• Medications
• Information sources: National Foundation for Ileitis and
Colitis
• Ileostomy care if applicable
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Patient with an Intestinal Diversion
• See Charts 38-4, 38-5, and 38-7
• Preoperative care
• Postoperative care
• Emotional support
• Skin and stoma care
• Irrigation of a Kock’s pouch (continent ileostomy).
See Chart 38-6
• Diet and fluid intake
• Prevention of complications
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Appendicitis
• Inflammation of the vermiform appendix
• ETIOLOGY: usually fecalith, lymphoid hyperplasia, foreign
body and helminthic obstruction
• PATHOPHYSIOLOGY Obstruction of lumen
increased
pressure
decreased blood supply
bacterial proliferation
and mucosal inflammation
ischemia
necrosis
rupture
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical manifestations
• Abdominal pain: begins in the umbilicus then localizes in
the RLQ (Mc Burney’s point)
• Anorexia
• Nausea and Vomiting
• Fever
• Rebound tenderness and abdominal rigidity (if
perforated)
• Constipation or diarrhea
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
DIAGNOSTIC TESTS
• 1. CBC- reveals increased WBC count
• 2. Ultrasound
• 3. Abdominal X-ray
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Interventions
Preoperative care
• NPO Consent Monitor for perforation and signs of shock
• Monitor bowel sounds,
• fever and hydration status
• POSITION of Comfort: RIGHT SIDELYING in a low
FOWLER’S
• Avoid Laxatives, enemas & HEAT APPLICATION
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Interventions
Post-op Care
• Monitor VS and signs of surgical complications
Maintain
• NPO until bowel function returns If rupture occurred,
• expect drains and IV antibiotics
• RIGHT side-lying
• semi- fowler’s to decrease tension on incision, and
legs flexed to promote drainage
• Administer prescribed pain medications
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intestinal Obstructions
• Mechanical obstruction
• Functional obstruction
• Small bowel
• Large bowel
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intestinal Obstruction
• Blockage of intestinal tract that inhibits
passage of fluid, gas, feces
• Caused by
– mechanical obstruction (strangulated
hernia, adhesion, cancer, volvulus,
intussusception)
– neurogenic obstruction (paralytic ileus,
uremia, electrolyte imbalance(low K),
spinal cord lesion)
– Vascular disease (occlusion of superior
mesentery vessels)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intestinal Obstructions
• Paralytic Ileus or “silent bowel” is most often seen after
abdominal surgery & anesthesia
• bowel activity is < due to lack of neural stimuli
(“functional”)
• this can lead to “mechanical” obstruction due to
accumulation of feces
• Hernias: a loop of bowel protrudes through abdominal
wall
• inguinal canal, umbilicus, or incisional scar tissue
• caused by heavy lifting, straining, or coughing
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sigmoid Volvulus
• Sigmoid Volvulus (twisting): usually seen in the
older individual with a history of straining at stool
– Symptoms: abdominal distention, nausea,
vomiting, and crampy abdominal pain; check
history of flatus and BMs
– Abrupt onset is indicative of an acute
obstruction
– Sudden onset due to “torsion or hernia?”
• A chronic history of constipation is related to a dx
of diverticulitis or carcinoma
• Obstipation (no flatus or BM) & loss of weight =
carcinoma
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sigmoid Volvulus
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intussusception
• only 5-15 % occurrence in adults
• s/s colicky abd pain, nausea, vomit, diarrhea,
constipation
• diagnosed by barium enema, CT scan
• treated via surgical resection
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Causes of Intestinal Obstructions
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Intussusception
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Small Bowel Obstruction
Causes of small bowel obstruction include:
•
Adhesions from previous abdominal surgery
•
Hernias containing bowel
•
Crohn's disease causing adhesions or inflammatory strictures
•
Neoplasms benign or malignant
•
Intussusception in children
•
Volvulus
•
Superior mesenteric artery syndrome a compression of the duodenum by
the superior mesenteric artery and the abdominal aorta
•
Ischemic strictures
•
Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects)
•
Intestinal atresia
•
Parasites
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Small Bowel Obstruction
Signs & Symptoms of Small Bowel
Obstruction:
 Abdominal pain
Vomiting
 Elimination problems (Diarrhea)
 Bloating
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Small Bowel Obstruction
The essentials:
* Common, may or may not require surgery
* Emergent, if bowel is strangulated (to OR)
* KUB not necessarily diagnostic
-Shows dilated loops, air-fluid levels
* CT very sensitive and specific
-Better at transitional zone, cause of SBO
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Large Bowel Obstruction
• A large bowel obstruction is an emergency
condition that requires early & prompt surgical
intervention
• Etiology:
• infectious / inflammatory, neoplastic, or
mechanical pathology (colorectal cancer)
• Rotation or twisting of the cecum or sigmoid
colon will cause abrupt onset of symptoms
• Immediate abdominal distention
– Decreases the ability to absorb Fluids &
Electrolytes
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Large Bowel Obstruction
Causes of large bowel obstruction
include:
• Neoplasms
• Hernias
• Inflammatory bowel disease
• Colonic volvulus (sigmoid, caecal, transverse
colon)
• Fecal impaction
• Colon atresia
• Benign strictures (Diverticular Disease)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Large Bowel Obstruction
Signs & Symptoms of Large Bowel
Obstruction:
 Abdominal pain
Vomiting (not common)
 Elimination problems (Constipation or
Loose)
 Bloating
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
When to Operate?
• Incarcerated or strangulated hernia
• Peritonitis
• Pneumoperitoneum
• Suspected strangulation
• Closed loop obstruction
• Complete obstruction
• Virgin abdomen
• LARGE bowel obstruction
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Placement of Colostomies
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
Regular bowel habits can be established for a patient with
an ileostomy.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
False
Regular bowel habits can NOT be established for a patient
with an ileostomy.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anorectal Conditions
• Anorectal abscess
• Anal fistula
• Anal fissure
• Hemorrhoids
• Sexually transmitted anorectal diseases
• Pilonidal sinus or cyst
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hemorrhoids
Abnormal dilation and weakness of the veins of the anal
canal Variously classified as Internal or External,
Prolapsed, Thrombosed and Reducible
PATHOPHYSIOLOGY Increased pressure in the
hemorrhoidal tissue due to straining, pregnancy, etc
dilatation of veins
Internal hemorrhoids These dilated veins lie above the
internal anal sphincter Usually, the condition is PAINLESS
External hemorrhoids These dilated veins lie below the
internal anal sphincter Usually, the condition is PAINFUL
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical manifestations
• Internal hemorrhoids- cannot be seen on the peri-anal
area
• External hemorrhoids- can be seen
• Bright red bleeding with each defecation
• Rectal/ perianal pain
• Rectal itching
• Skin tags
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic test
• Anoscopy
• Digital rectal examination
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Interventions
Basic Care & comfort
Post-op care
• Advise patient to apply cold
packs to the anal/rectal
area followed by a SITZ
bath
• Position: Prone or Sidelying
• Apply astringent like witch
hazel soaks
• Maintain dressing over the
surgical site
• 3. Monitor for bleeding
• Encourage HIGH-fiber diet
and fluids
• 4. Administer analgesics
and stool softeners
• Administer stool softener
as prescribed
• 5. Advise the use of SITZ
bath 3-4 times a day
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Anal Lesions
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pilonidal Sinus
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with an Anorectal Condition—Assessment
• Health history
• Pruritis, pain, or burning
• Elimination patterns
• Diet
• Exercise and activity
• Occupation
• Inspection of the area
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with an Anorectal Condition—Diagnoses
• Constipation
• Anxiety
• Acute pain
• Urinary retention
• Risk for ineffective therapeutic regimen management
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Collaborative Problems/Potential
Complications
• Hemorrhage
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Process: The Care of the Patient
with an Anorectal Condition—Planning
• Major goals may include adequate elimination patterns,
reduction of anxiety, pain relief, promotion of urinary
elimination, management of the therapeutic regimen,
and absence of complications.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Interventions
• Encourage intake of at least 2 L water a day
• Recommend high-fiber foods
• Bulk laxatives, stool softeners, and topical medications
• Promote urinary elimination
• Hygiene and sitz baths
• Monitor for complications
• Teach self-care
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins