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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