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CH42 Lower Gastrointestinal Problems GIGU
Medical-Surgical Nursing II (NSG 223)
Herzing University
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CH 42 Lower Gastrointestinal Problems
Know acute vs chronic symptoms and treatment. Especially manifestations related to disease and medication choice. For instance acute IBD treatment with corticosteroids would not immediately raise the BG levels to critical level , chronic IBD and use would.
4 Diarrhea
Passage of at least 3 loose/liquid stools per day. Chronic 30 days or longer
Etiology
Viral, Bacterial, Parasitic microorganisms Medication - (PPI, H2 receptor blocker - decrease GI acidity, unwanted microorganisms are more likely to survive) Antibiotics - kills off normal flora, more susceptible to pathogens C Food intolerances
Diagnostic Test
Stool culture, H&H, BUN indicated signs of fluid deficit
Interprofessional Care
Fluid and electrolyte replacement (Pedialyte) Antidiarrheals (contraindicated w/ infectious diseases)
Nursing Management
Nursing Assessment – Hx (characteristics of stool, medications, food intolerances) & physical (assess for dehydration, abd distention, inspect perineal skin for redness Nursing Diagnosis
- Diarrhea r/t to acute infectious process
- Deficient fluid volume r/t excessive fluid loss and decreased fluid intake o Goals: (1) no transmission of microorganism causing infectious diarrhea (2) cessation of diarrhea and resumption of normal bowel pattern (3) normal fluid, electrolyte, & acid base balance (4) normal nutritional status (5) no perianal/perineal skin breakdown Nursing Implementation – treat all cases as infectious, proper hand hygiene o C. diff infection – place pt in isolation, PPE, discuss proper food handling, cooking & storage, disinfect surfaces w/ 10% bleach or disinfectant labeled C. diff sporicidal
Fecal Incontinence
Involuntary passage of stool
Etiology
Trauma – anorectal surgery, childbirth injury, perineal trauma or pelvic fracture Inflammatory – infection, inflammatory bowel disease, radiation Pelvic Floor Dysfunction – medications, rectal prolapse
Functional – immobility, fecal impaction Neurological – brain tumor, dementia, spinal cord injuries, stroke
Diagnostic Test & Interprofessional Care
Rectal exam (reveal anal muscle tone, hemorrhoids, fecal impaction, & masses Abd x-ray, CT, anorectal manometry, anorectal ultrasonography, defecography Sigmoidoscopy, colonoscopy Bowel management program (regular defecation, high fiber, caffeine free fluids) Dietary fiber supplement or bulk forming laxatives, antidiarrheals, kegel exercises Eliminate coffee, dried fruit, onions, mushrooms, green veggies, fruit with peels, spicy food Surgery (sphincter repair) or colostomy if necessary
Nursing Management
Nursing Assessment – identify bowel patterns, assess perineal area Nursing Implementation – bowel training, 30 mins after breakfast (keep bed pan, commode, walker close) o Bisacodyl (Dulcolax), small phosphate enema – 15-30 mins, digital stimulation – stimulate rectal reflex o Maintain perineal skin, fecal management o Advise pt to wear dark clothing, use bathroom when available, disposable brief & pads, access to spare clothing
Constipation
difficult or infrequent stools; hard, dry stools that’s are difficult to pass, or a feeling of incomplete evacuation
Etiology
Insufficient fiber, decrease physical activity, ignoring defecation urge, drugs Diseases that slow GI motility & affect neurological function (diabetes mellitus, Parkinson's disease, multiple sclerosis) Emotions (anxiety, depression, & stress)
Diagnostic Test & Interprofessional Care
Physical exam, abd x-ray, barium enema, colonoscopy, sigmoidoscopy, rectal balloon expulsion test, anorectal manometry, defecography w/ barium, fluoroscopy Increase dietary fiber, maintaining adequate fluid intake (2L), exercise Laxatives & Enemas (last resort) Fruits, vegetables, & grains, wheat, bran, prunes
Nursing Management
Nursing Assessment – Hx, medication, daily patterns, physical assessment Nursing Implementation – teach pt importance about diet, fluid, activity, prevention & tx o Teach pt to establish regular defecation time, not to suppress urge, proper positioning,
Diagnoses solely on symptoms – Rome III - abd pain & discomfort at least 3 months (3- months) associated w/ 2 or more o Improvement w/ defecation, change in stool frequency, change in stool appearance o IBS w/ constipation (WOMEN) o IBS w/ diarrhea, IBS w/ mixed, IBS subtyped (MEN) o Last bowel movement? Current diet? Medications? Stress? Food diary for incr/decr symptoms Collaborative Care & Nursing Management o Cognitive behavior & stress management, diary of symptoms and diet, regular exercise, acupuncture & hypnosis o Diet low in FODMAP (fructans [wheat, rye, onion, garlic], galactans, lactose, fructose), probiotics, high fiber o Drug therapy (antispasmodic – decrease GI motility, hyoscyamine, dicyclomine (Bentyl) or Aloestron (Lotronex) – women w/ severe pain & diarrhea o Avoid broccoli, & cabbage (gas forming)
4 Appendicitis
Inflammation of the appendix, narrow blind tube extending from end of cecum
Clinical Manifestation
dull periumbilical pain, anorexia, nausea, vomiting, persistent, continuous, eventually shifts to RLQ, low grade fever, localized tenderness, rigidity, older adult – less severe, slight fever, discomfort of iliac fossa, PAIN IN MCBURNEY’S POINT
Diagnostic Test & Interprofessional Care
hx, physical, WBC count (moderately elevated), urinalysis, CT scan is preferred test, ultrasound, MRI Appendectomy (Removal of appendix), antibiotics & fluids before surgery – prevents dehydration & sepsis (Ambulatory prodcedure, leaves the same day)
Nursing Management
Prevent fluid volume deficit, relieve pain, prevent complications NPO until HCP evaluates pt, monitor vitals, administer IV fluids, pain med & antiemetics as ordered, post op care, early ambulation, diet advances as tolerated
Peritonitis
Localized/generalized inflammation of the peritoneum Causes – blood borne organism, abd organ rupture or perforation (release content, bile, enzymes, & bacteria into peritoneal cavity), cirrhosis with ascites
Clinical Manifestation
Abd pain, tenderness, muscular rigidity & spasm, pt may only take shallow breaths, abd distention, fever, tachycardia, tachypnea, nausea, vomiting, & altered bowel habits
Complications – hypovolemic shock, sepsis, intraabd abscess formation, paralytic ileus, & acute resp distress syndrome
Diagnostic Tests & Interprofessional Care
CBC with WBC differential, abd paracentesis & culture of fluid, abd x-ray, peritoneoscopy, Ct, ultrasound Antibiotics, NG suction, analgesics & IV admin Surgery – indicate cause of inflammation, drain purulent fluid, & repair damages
Nursing Management
Nursing Assessment – asses pain, assess bs, abd distention, guarding, nausea, fever* manifestations of hypovolemic shock (decr BP, rapid weak HR, pallor, cold/clammy, rapid shallow breaths, decr UO) manifestations of septic shock (decr BP, chills, fever, rapid confusion, difficulty breathing) Nursing Diagnosis – 1). Acute pain r/t inflammation of the peritoneum & abd distention o 2). Risk for deficient fluid volume r/t fluid shift into peritoneal cavity secondary to trauma, infection or ischemia o 3). Anxiety r/t uncertainty o Goals: 1). Resolution of inflammation, 2). Relief of abd pain, 3). Freedom from complications (sepsis, hypovolemic shock), 4). Normal nutritional status Nursing Implementation – NPO, IV replacement fluids, monitor for pain and response to analgesic, position w/ knees flexed for comfort, sedatives for anxiety o Monitor I&O and electrolytes, antiemetics, NG tube for gastric distention, low flow O therapy, w/ open procedure pt has drains for purulent drainage
Inflammatory Bowel Disease
Chronic inflammation of the GI tract w/ periods of remission & exacerbation
Diagnostic Test
CBC (elevated erythrocyte sedimentation rate, elevated WBC count), serum chemistry (decreased sodium, potassium, chloride, bicarb, magnesium, hypoalbuminemia), occult blood testing, CT, MRI, colonoscopy,
Interprofessional Care
Aminosalicylates – decrease inflammation by suppressing proinflammatory cytokines (more effective in ulcerative colitis, first line of treatment given, can be given in crohns if mild to moderate) o Sulfasalazine findings: Discoloration of skin and urine o Avoid UV rays o Men: abnormal sperm production (temporary) o Side effects: nausea/vomiting, headache, fatigue Antimicrobials – prevent/treat secondary infection o Side effects: diarrhea Corticosteroids – decrease inflammation, monitor BGL, MUST be tapered off o MAY CAUSE OSTEOPROSIS o HAS MOON FACE o High blood sugar Immunosuppressants – suppress immune response (after steroids tapered off) Imuran o Monitor CBC, liver enzymes, and pancreatic enzymes may cause supression of bone marrow o Advise women of child bearing age to AVOID PREGNANCIES when taking Methotrexate Biologic & target therapy – inhibit cytokine tumor necrosis factor & prevent migration of leukocytes from bloodstream to inflamed tissue (Does not work for everyone) o Infliximab given IV to reduce remission in patients with Crohn’s disease o Integrin receptor antagonists: HEPATOTOXIC o TNF agents side effects: upper respiratory, UTI, hepatitis and TB, infections and lymphomas. Ulcerative colitis (drainage of abd abscess, intestinal obstruction, fistula, perforation) o Total proctocolectomy w. ileal pouch/anal anastomosis – diverting ileostomy & pouch is created & anastomosed to anus. 2 surgery process. Colectomy, mucosectomy, ileal pouch (reservoir) construction, ileoanal anastomosis, temp ileostomy 2 nd surgery closure of ileostomy, divert stool to pouch Complication: ACUTE OR CHRONIC POUCHITIS o Total proctocolectomy w. permanent ileostomy – removal of colon, rectum, & anus with closure of anal opening. Terminal ileum brought out thru abd wall form stoma Continence is not possible (Incontinent) Crohn disease (complications like strictures, obstructions, bleeding, & fistulas) o Most surgeries involve rejection of diseased colon & anastomosis of remaining site o Structureplasty – opening up narrowed areas
o Complication: SMALL BOWEL SYNDROME Monitor stoma visibility, observe for s/s of fluid & electrolyte imbalance, dehydration, small bowel obstruction, hemorrhage, perianal skin care Nutritional Therapy – balanced healthy diet, High Protein, parenteral or iv nutrition may be needed, cobalamin injections, supplemental iron, folic acid such as leafy green vegetables (pt taking sulfasalazine), potassium and calcium supplements for osteoporosis (w/ corticosteroids), vitamin D supplements to absorb calcium, liquid enteral nutrition
Nursing Management
Nursing assessment – hx, medications, eating habits, GI assessment Nursing Diagnosis – 1). Diarrhea r/t bowel inflammation & intestinal hyperactivity o 2). Imbalanced nutrition: less than body requirements r/t decreased absorption & increased nutrients loss thru diarrhea o 3). Ineffective coping related to chronic disease, lifestyle changes, inadequate confidence in ability to cope o Goals: 1) fewer exacerbations 2). Maintain normal fluid & electrolyte balance, 3). Free of pain & discomfort, 4). Adhere to medical regimen 5). Maintain nutritional balance 6). Improved quality of life Nursing implementation – hemodynamic stability, pain control, fluid & electrolyte balance, nutritional support, I&O records, monitor stool appearance. Administer iv fluids, anti- inflammatory meds o Keep pt clean & dry until diarrhea is controlled o Daily weight, enough rest, no smoking, o POST OP SURGERY: if UOP is 0 ml/kg, notify the doctor o GIVE QUESTRAN TO DECREASE DIARRHEA o POST OP ileostomy: Stoma care (skin integrity) I&O (Output 1500-1800 ml per hour Kegel exercises Perianal skin care (for diarrhea) Pericare o Teachings When to seek medical care Drugs How to manage chronic illness Ways to reduce stress
Gastroenteritis
Breath odor
Complications
F N E imbalances Jaundice Grangrene tissue (black)
Diagnostic Test
Hx, physical, CT scan, abd x-ray, sigmoidoscopy, colonoscopy, CBC (elevated WBC = strangulation or perforation), H&H, serum electrolytes, BUN, creatinine CT is more common to do, less invasive and visualizes everything, fast results
Interprofessional Care
Place pt on NPO status, NG tube for decompression, IV fluids (NS or lactated Ringer’s) WITH POTASSIUM, pain meds, parenteral nutrition (IV thru TPN central line [watch for hyperglycemia and infection]) Surgery (resecting obstructed segment), colonoscopy (remove polyps, dilate strictures, or remove & destroy tumors) Stent placement along with corticosteroids w/ antiemetics properties
Nursing Management
Nursing Assessment - pt history, physical exam, pain assessment (determine location, duration, intensity & frequency) o Record vomit (onset, frequency, color, odor & amount, assess bowel function & BS o I&O, urinary catheter o Measure abd girth, muscle guarding and tenderness Nursing Diagnosis – 1). Acute pain r/t abd distention & increased peristalsis o 2). Deficient fluid volume r/t decrease in intestinal fluid absorption, third space fluid shift into bowel lumen & peritoneal cavity, NG suction & vomiting o Goals: 1). Relief from obstruction & return to normal bowel function, 2). Minimal to no discomfort, 3). Normal fluid & electrolyte & acid base status Nursing Implementation – monitor for signs of dehydration & electrolyte imbalances, watch for fluids overload w. IV, comfortable measure for rest, oral hygiene o Post Op Care o REPORT IF UOP IS LESS THAN 0 ML/KG (INADEQUATE VASCULAR VOLUME AND AKI) o Monitor elevated BUN and creatinine o NG tube care First 12 hours dark brown or dark red drainage After 12 hours light yellowish brown, possibly tinged green from bile IF DARK RED AFTER 12 HOURS CONTACT HCP
4 Colorectal Cancer
Etiology
Risk factors: Family hx, IBD, obesity, red meat, cigarette, alcohol, diabetes mellitus KRAS gene (class of oncogenes) Factors that DECREASE CRC o Exercise o Diet high in fruits, vegetables, and grains o NSAIDS (long term) Brain and liver can have secondary cancer (metastasis)
Clinical Manifestation
Asymptomatic until disease advances Early Stages: fatigue, weight loss (significant) Iron deficiency anemia, rectal bleeding, abd pain, changes in bowel habit, intestinal obstruction or perforation Advanced disease – abd tenderness, palpable abd mass, hepatomegaly, ascites Complications: obstruction, bleeding, perforation, peritonitis & fistula formation (abnormal connection b/w organs) Right sided lesion causes diarrhea, left sided tumor causes bowel obstruction
Diagnostic Test
Hx, physical, colonoscopy, sigmoidoscopy, occult blood, CBC, liver function tests, barium enema, CT scan, ultrasound, MRI (NO METAL OF ANY KIND ON BODY) carcinoembryonic antigen (CEA) test o blood test (glycoprotein produced by CRC cells) o used for disease recurrence after chemo or surgery
Interprofessional Care
Surgery (complete resection, through exploration, removing lymph nodes that drain area, restoring bowel continuity, preventing complications) Abdominal perineal resection – removal of the entire rectum, leaving pt with a permanent colostomy Low anterior resection – preserves sphincters, remove rectum anastomosing canal & anal canal, pt requires temporary ileostomy and colostomy to divert stool & allow anastomosis to heal Chemo & Target Therapy o CHEMO MED SIDE EFFECTS: N/V, NEPHROTOXIC, FATIGUE, IMMUNOSUPPRESSED Radiation Stage I: remove tumor and 5 cm of intestine on either side of intestine Stage II o Low-risk: wide resection and anastomosis o High-risk: chemotherapy Stage III: surgery and chemotherapy (radiation might be done before to reduce tumor)
4 Ostomy Surgery
Ostomy – surgically created opening on the abd that allows drainage of body waste Stoma – large or small bowel brought to the outside of the abd & sutured in place Necessary when the natural route is no longer possible o Named based on location, ileostomy – ileum, colostomy – colon Ileostomy output – liquid – thin paste, involuntary, drain frequently, much wear ostomy appliance pouch Output from a sigmoid colon resembles normal formed stool
End Stoma – divide bowel and proximal end brought out as a single stoma, making colostomy or ileostomy
Distal end suture or removed, if removed stoma becomes permanent
Loop Stoma – loop of the bowel brought to abd surface, anterior wall opened to provide fecal diversion
Results in proximal opening for feces & distal end of mucus drainage. Held in place by plastic rod
Double Barreled Stoma – bowel is divided, both ends brought thru abd wall as separate stomas.
Proximal one functional stoma, distal mucus fistula. Usually temporary
Nursing Management
Pt requires emotional support & pt/caregiver teaching about ostomy care PreOp Care – psychological preparation & emotional support (allow pt to verbalize concerns & questions) enhances ability to cope o WOCN marks placement of ostomy (w/in rectus muscle & flat surface) o WOCN should determine pt ability to selfcare PostOP Care – assessment of stoma Q4H (rosy pink/brick red - viable, pale – indicate anemia, dusky blue – ischemia, brown-black – necrosis) make sure there is no bleeding, colostomy starts functioning when peristalsis returns o Record COCA of drainage. Bleeding small amount oozing – normal b/c of high vascularity. Moderate to large amount – potential GI bleed, portal hypotension Colostomy Care – appropriate pouching system, don’t allow feces to remain on skin, irritation will quickly develop o Ascending & transverse colostomy (semi-liquid stool), require drainage pouch, lasts 4- days o Sigmoid or descending colostomy semi-formed to formed stool), may use drainage pouch or disposable pouch, changed daily o Irrigation – regulates emptying of colon, may not need regular pouch o Teaching – emptying & changing pouch, food & fluid requirements, how to get help, skin care, managing gas & odor, care of stoma, potential complications, resuming daily activity,
o Colostomy Irrigation – stimulate emptying of colon, regular emptying trains bowels, may only require pad or small pouch, pt should still have ostomy bags available in case of diarrhea from food or illness Ileostomy Care – pouch required at all times, observe pt for s/s of fluid & electrolyte imbalances (K, Na, & fluid deficit) o May experience high volume output (1,500-1,800 mL/day) when peristalsis returns, after adjustment avg 500mL/day, pt must increase fluid intake by 2-3L/day with excess fluid loss from heat/sweat & more Na ingestion, Pt must learn s/s of fluid & electrolyte imbalance o Ileostomy susceptible to obstruction, lumen is 1in in diameter & narrows further, pt must chew foods
4 Diverticulosis and Diverticulitis
diverticula – dilated sac or outpouchings of the mucosa that develop in the colon diverticulosis – multiple noninflamed diverticula diverticulitis – inflammation of one or more diverticula, resulting in perforation into the peritoneum common in the left (sigmoid/descending) colon main factor: lack of dietary fiber, obesity, inactivity, smoking, excessive alcohol use, immunosuppression
Clinical Manifestation
Diverticulosis – no symptoms, those w/ symptoms – abd pain, bloating, flatulence, & changes in bowel habits. Serious cause diverticula bleed or become diverticulitis Diverticulitis – acute pain LLQ (sigmoid colon), palpable abd mass, nausea, vomiting, & systemic symptoms of infection (fever, increased C-reactive protein, leukocytosis) o Can cause erosion of bowel & perforation into peritoneum, localized abscess develops (body walls off perforation), peritonitis develops, extensive bleeding
Diagnostic Test
Hx, physical, Sigmoidoscopy, colonoscopy, biopsy, CBC, occult blood test, urinalysis, barium enema, blood culture, CT scan with oral contrast, abd/chest x-ray
Interprofessional Care & Nursing Management
Prevention – high fiber diet (fruits/veggies), increase fluids at least 2L/day, decrease in fat & red meat, high physical activity, Diverticulitis – allow colon to rest & inflammation to subside, oral antibiotics & clear liquid diet Hospitalization if severe, NPO, IV fluid & antibiotics, observe for signs of abscess, bleeding, peritonitis & monitor WBC count, pain meds, Surgery (pt has frequent diverticulitis or complications, abscess or obstruction) o Resection of colon w/ anastomosis, possible temporary colostomy
External hemorrhoids reddish blue, seldom bleed, mostly itch, burn & edema, painful when there is a thrombosis (blood clot) Thrombosed hemorrhoids are bluish purple palpable at anal orifice
Diagnostic Test & Interprofessional Care
Internal hemorrhoid – diagnosed by digital exam, anoscopy, sigmoidoscopy External easily diagnosed – visual inspection & digital exam High fiber diet & increased fluid prevents constipation & reduce straining Dibucaine creams, suppositories, & impregnated pads w/ anti-inflammatory agents (hydrocortisone) or astringents & anesthetics (witch hazel, benzocaine) shrink mucous membrane & relieve discomfort Stool softener keep stool soft & sitz bath help relieve pain Internal hemorrhoids – rubber band ligation, infrared coagulation, sclerotherapy, laser treatment Hemorrhoidectomy – surgical excision of hemorrhoids (indicated w/prolapse, excessive pain or bleeding or large multiple thrombosed hemorrhoids (cautery, excision or clamping)
Nursing Management
Teach pt to prevent constipation, avoid prolonged standing/sitting & proper use of hemorrhoid meds Seek medical care for severe symptoms (excessive bleeding, pain, prolapsed hemorrhoids Sitz bath 15-20mins 2-3x's per day reduce swelling & discomfort Hemorrhoidectomy- Pain meds & topical ointment to provide analgesia & reduce sphincter spasm (glyceryl trinitrate (GTN), calcium channel blockers (nifedipine w/ lidocaine, diltiazem) or nitroglycerin preparations Pain meds b4 bowel movement, stool softener, pt doesn’t move bowel in 2/3 days oil retention enema, sitz bath, comfort when sitting pressure relief cushions
Anal Fissure
Skin ulcer, or crack in lining of the anal wall Cause – passage of hard stool, trauma (anal intercourse, insertion of foreign objects), local infection (syphilis, tuberculosis, gonorrhea, chlamydia, herpes, HIV) Severe pain, acute (less than 6 weeks) bleed slightly, constipation w/ fear of pain Fiber supplements, adequate fluid intake, sitz bath, topical analgesics, topical preparations (nitrates, calcium channel blockers, stool softener
Anorectal Abscess
Collection of perianal pus Obstruction of anal glands, leading to infection & abscess formation Severe pain & swelling, foul smelling drainage, tenderness, elevated temp, sepsis as complication Surgical drainage, larger abscess requires packing afterwards w/ impregnated gauze or placement of drains (penrose)
Immunocompromised will require antibiotics Warm moist heat applications, pt lays on abd or side. Low fiber diet Teach pt about wound care and sitz bath, cleaning after urinating or bowel movements
Anal Fistula
Abnormal tunnel leading from the anus or rectum (outside skin, vagina, buttocks Feces may enter & cause infection, may be persistent, bloody, or purulent drainage or stool leakage Pt may need to wear pad Surgical tx depends on location & nature o Fistulotomy – surgeon opens fistula and healthy tissue is allowed to granulate in the wound o Complex – ligation of the intersphincteric fistula tract (LIFT), or use of rectal flaps, setons, plugs or fibrin glue injections to seal fistula
Anal Cancer
Associated w/ HPV Rectal bleeding, rectal pain, & sensation of s rectal mass Review behavior to decrease risk of sexually transmitted disease Encourage condom use, avoid unprotected anal sex, limit sexual partners, vaccination for HPV Tx depends on size & depth of lesion topical bichloroacetic or trichloroacetic aid to remove genital warts & kill HPV Surgical removal or precancerous lesion or Chemo
Pilonidal Sinus
Small tract under skin between buttocks sacrococcygeal area Movement causes hair to penetrate skin, if irritated becomes infected, forms a cyst or abscess Pain and swelling @ base of spine Requires incision & drainage Warm moist heat application w/ abscess present Teach pt to avoid contaminating dressing when urinating or defecating & avoid straining
CH42 Lower Gastrointestinal Problems GIGU
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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