Chapter 41: Management of Patients with Intestinal and Rectal Disorders

Planning and Goals for the Patient with Inflammatory Bowel Disease

- 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, Therapeutic regimen, Avoidance of complications

Clinical Manifestations of Irritable Bowel Syndrome

-Alteration in bowel patterns -Pain -Bloating -Abdominal distention

Fecal Incontinence: Causes

-Anal sphincter weakness -Traumatic (e.g., after surgical procedures involving the rectum) and nontraumatic (e.g., scleroderma) -Neuropathies both peripheral (e.g., pudendal) and generalized (e.g., diabetes) -Disorders of the pelvic floor (e.g., rectal prolapse) -Inflammation (radiation proctitis, IBD) -Central nervous system disorders (e.g., dementia, stroke, spinal cord injury, multiple sclerosis) -Diarrhea; fecal impaction with overflow -Behavioral disorders

Appendicitis

-Appendicitis is the most frequent cause of acute abdomen in the United States, most common reason for emergency abdominal surgery -Appendix becomes inflamed and edematous as a result of becoming kinked or occluded by a fecalith or lymphoid hyperplasia -The inflammatory process increases intraluminal pressure, causing edema and obstruction of the orifice -Once obstructed, the appendix becomes ischemic, bacterial overgrowth occurs, and eventually gangrene or perforation occurs

Other Nursing Interventions for the Patient with Inflammatory Bowel Disease

-Assessment and treatment of pain or discomfort, anticholinergic medications before meals, analgesics, positioning, diversional activities, and prevention of fatigue -Fluid deficit, I&O, daily weight, assessment of symptoms of dehydration or 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, use a calm manner, allow patient to express feelings, listening, patient education

Assessment of the Patient Receiving Parenteral Nutrition

-Assist in identifying patients who are candidates for PN: Nutrition status; decreased oral intake >1 week, Weight loss 10% or more of usual weight, Muscle wasting, decreased tissue healing, Persistent N&V -Hydration status -Electrolytes -Caloric intake

Patient Learning Needs for Fecal Incontinence

-Bowel training program -Skin care -Emotional support

Assessment and Diagnostic Findings of Diarrhea

-CBC -Serum chemistries -Urinalysis -Stool examination -Endoscopy or barium enema

Celiac disease

-Celiac disease is a disorder of malabsorption caused by an autoimmune response to consumption of products that contain the protein gluten -Gluten is most commonly found in wheat, barley, rye, and other grains malt, dextrin, and brewer's yeast -Celiac disease has become more common in the past decade, with an estimated prevalence of 1% in the United States -Women are afflicted twice as often as men -Type 1 diabetes, Down syndrome, Turner syndrome

Management of Celiac Disease

-Celiac disease is chronic, noncurable, lifelong -No medications to treat -Refrain from exposure to gluten in foods -Consult with dietician

Assessment and Diagnostic Findings of Constipation

-Chronic constipation is usually idiopathic -Further testing for severe, intractable constipation -Thorough history and physical examination -Barium enema, sigmoidoscopy, and stool testing -Defecography and colonic transit studies -MRI

Irritable Bowel Syndrome

-Chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea, constipation, or both -15% of adults in the United States report symptoms of IBS; More common in women than men -Triggers: chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods

Inflammatory Bowel Disease

-Crohn's disease (regional enteritis)= a type of inflammatory bowel disease (IBD). It causes swelling of the tissues (inflammation) in your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition. -Ulcerative colitis= an inflammatory bowel disease (IBD) that causes inflammation and ulcers (sores) in your digestive tract. *Perianal involvement, fistulas, and abdominal mass are common in Crohn's disease.

Complications of Constipation

-Decreased cardiac output -Fecal impaction -Hemorrhoids -Fissures -Rectal prolapse -Megacolon

Constipation

-Defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass -Causes include medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra-abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise -Perceived constipation: a subjective problem in which the person's elimination pattern is not consistent with what he or she believes is normal

Manifestations of Celiac Disease

-Diarrhea -Steatorrhea -Abdominal pain -Abdominal distention -Flatulence -Weight loss

Diverticular Disease

-Diverticulum: sac-like herniation of the lining of the bowel that extends through a defect in the muscle layer -May occur anywhere in the intestine but 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

Collaborative Problems and Potential Complications of the Patient with Inflammatory Bowel Disease

-Electrolyte imbalance -Cardiac dysrhythmias -GI bleeding with fluid loss -Perforation of the bowel

Nursing Management of Diverticulitis

-Encourage fluid intake of at least 2 L/day -Soft foods with increased fiber, such as cooked vegetables -Individualized exercise program -Bulk laxatives (psyllium) and stool softeners *The most common site for diverticulitis is the sigmoid.

Nursing Interventions for the Patient with an Anorectal Condition

-Encourage intake of at least 2 L of water a day -Recommend high-fiber foods -Bulk laxatives, stool softeners, and topical medications -Promote urinary elimination -Hygiene and sitz baths -Monitor for complications -Educate on self-care

Assessment and Diagnostic Findings of Malabsorption

-Fat analysis -Lactose tolerance tests -D-xylose absorption tests -Schilling tests -Hydrogen breath test -Endoscopy with biopsy -Ultrasound, CT, radiography -CBC, pancreatic function tests

Manifestations of Constipation

-Fewer than three bowel movements per week -Abdominal distention, pain, and bloating -A sensation of incomplete evacuation -Straining at stool -Elimination of small-volume, hard, dry stools

Complications of Diarrhea

-Fluid and electrolyte imbalances -Dehydration -Cardiac dysrhythmias -Chronic diarrhea can result in skin care issues related to irritant dermatitis

Patient Education for the Patient Receiving Parenteral Nutrition

-Goals and purpose -Components of PN -Emergency contact numbers -Demonstrate use of equipment and how to handle and hang the IV -Demonstrate dressing changes -Demonstrate how to flush or heparinize the catheter -Potential complications and actions

Nursing Management of Intestinal Obstruction

-Goals include: Maintaining the function of the nasogastric tube, Assessing and measuring the nasogastric output, Assessing for fluid and electrolyte imbalance, Monitoring nutritional status, and Assessing for manifestations consistent with resolution (e.g., return of normal bowel sounds, decreased abdominal distention, subjective improvement in abdominal pain and tenderness, passage of flatus or stool)

Nursing Management of Appendicitis

-Goals include: Relieving pain, Preventing fluid volume deficit, Reducing anxiety, Preventing or treating surgical site infection, Preventing atelectasis, Maintaining skin integrity, Attaining optimal nutrition

Clinical Manifestations of Malabsorption

-Hallmark finding is diarrhea or frequent, loose, bulky, foul-smelling stools, high-fat content, and often grayish -Symptoms similar to irritable bowel syndrome -Manifested by weight loss and vitamin and mineral deficiency

Assessment of the Patient with Cancer of the Colon or Rectum

-Health history -Fatigue and weakness -Abdominal or rectal pain -Nutritional status and dietary habits -Elimination patterns -Abdominal assessment -Characteristics of stool

Assessment of the Patient with an Anorectal Condition

-Health history -Pruritus, pain, or burning -Elimination patterns -Diet -Exercise and activity -Occupation -Inspection of the area

Assessment of the Patient with Inflammatory Bowel Disease

-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

Assessment and Diagnostic Findings of Fecal Incontinence

-History to determine etiology -Rectal examination -Endoscopic examinations -Radiography studies -Barium enema -CT -Anorectal manometry

Manifestations of Diarrhea

-Increased frequency and fluid content of stools -Abdominal cramps -Distention -Borborygmus -Anorexia and thirst -Painful spasmodic contractions of the anus -Tenesmus

Diarrhea

-Increased frequency of bowel movements (more than three per day) with altered consistency (i.e., increased liquidity) of stool -Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors -May be acute, persistent, or chronic -Causes include infections, medications, tube feeding formulas, metabolic and endocrine disorders, and various disease processes

Indications for Parenteral Nutrition

-Intake is insufficient to maintain anabolic state -Ability to ingest food orally or by tube is impaired -Patient is not interested or is unwilling to ingest adequate nutrients -The underlying medical condition precludes oral or tube feeding -Preoperative and postoperative nutritional needs are prolonged *Parenteral nutrition is a method of supplying nutrients to the body by the intravenous route. Intravenous fat emulsion is an oil-in-water emulsion of oils, egg phospholipids, and glycerin. A central venous access device is designed and used for long-term administration of medications and fluids into central veins. Total nutrient admixture is lipid emulsions, proteins, carbohydrates, electrolytes, vitamins, trace minerals, and water.

Intestinal Obstruction

-Intestinal obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract -Mechanical obstruction: Intraluminal obstruction or mural obstruction from pressure on the intestinal wall -Functional or paralytic obstruction: The intestinal musculature cannot propel the contents along the bowel, The blockage also can be temporary and the result of the manipulation of the bowel during surgery

Collaborative Problems and Potential Complications of the Patient with Cancer of the Colon or Rectum

-Intraperitoneal infection -Complete large bowel obstruction -GI bleeding -Bowel perforation -Peritonitis, abscess, and sepsis

Nursing Interventions for the Patient with Inflammatory Bowel Disease

-Maintaining normal elimination patterns: Identify relationship between diarrhea and food, activities, or emotional stressors, Provide ready access to bathroom or commode, Encourage bed rest to reduce peristalsis, Administer medications as prescribed, Record frequency, consistency, character, and amounts of stools

Nursing Interventions for the Patient Receiving Parenteral Nutrition

-Maintaining optimal nutrition: Daily weight at same time of day, Accurate I&O, Caloric count, Trace elements included in solution -Preventing infection: Appropriate catheter and IV site care, Strict sterile technique for dressing changes, Wear mask when changing the dressing, Assess insertion site, Assess for indicators of infection, Proper IV and tubing care -Maintaining fluid balance: Use infusion pump. Flow rate should not be increased or decreased rapidly. If fluid runs out, hang 10% dextrose solution, Monitor indicators of fluid balance and electrolyte levels, I&O, Weights, Monitor blood glucose levels

Planning and Goals for the Patient Receiving Parenteral Nutrition

-Major goals include: Attaining an optimal level of nutrition, Absence of infection, Adequate fluid volume, Optimal level of activity, Knowledge of self-care, Absence of complications

Planning and Goals for the Patient with an Anorectal Condition

-Major goals may include: Adequate elimination patterns, Reduction of anxiety, Pain relief, Promotion of urinary elimination, Management of the therapeutic regimen, Absence of complications

Planning and Goals for the Patient with Cancer of the Colon or Rectum

-Major goals may include: Attainment of optimal level of nutrition, Maintenance of fluid and electrolyte balance, Reduction of anxiety, Knowledge of diagnosis and treatment, Self-care ability, Optimal tissue healing, Protection of peristomal skin, Expressing feelings and concerns, Avoidance of complications

Patient Learning Needs for Irritable Bowel Syndrome

-Medication management -Complimentary medicine -Dietary changes -Food diary -Adequate fluid intake -Avoid alcohol and smoking -Relaxation techniques

Manifestations of Fecal Incontinence

-Minor soiling -Occasional urgency -Loss of control -Complete incontinence

Patient Learning Needs for Constipation

-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 *Polyethylene glycol and electrolytes is an osmotic agent. Bisacodyl is a stimulant laxative. Ducosate is an emollient stool softener. Magnesium hydroxide is a saline agent.

Collaborative Problems and Potential Complications of the Patient Receiving Parenteral Nutrition

-Pneumothorax, air embolism -Clotted or displaced catheter -Sepsis -Hyperglycemia -Rebound hypoglycemia -Fluid overload

Nursing Interventions for the Patient with Cancer of the Colon or Rectum

-Preparing the patient for surgery -Emotional support -Providing postoperative care -Maintaining optimal nutrition -Providing wound care -Monitoring and managing complications -Removing and applying the colostomy appliance -Irrigating the colostomy -Supporting a positive body image -Discussing sexuality issues -Promoting home and community-based care

Anorectal Conditions

-Proctitis -Anorectal abscess -Anal fistula -Anal fissure -Hemorrhoids -Pilonidal sinus or cyst

Patient Learning Needs for Diarrhea

-Recognition of need for medical treatment -Rest -Diet and fluid intake -Avoid irritating foods, including 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

Assessment and Diagnostic Findings of Irritable Bowel Syndrome

-Stool studies -Contrast radiography studies -Proctoscopy -Barium enema -Colonoscopy -Manometry -Electromyography

Malabsorption

-The inability of the digestive system to absorb one or more of the major vitamins, minerals, or nutrients -Conditions: Mucosal (transport) disorders, Infectious disease, Luminal disorders, Postoperative malabsorption, Disorders that cause malabsorption of specific nutrients

Colorectal Cancer

-The third most common site of new cancer cases in the United States -Risk factors -Importance of screening procedures -Manifestations may include change in bowel habits; blood in stool—occult, tarry, bleeding; tenesmus; symptoms of obstruction; pain, either abdominal or rectal; feeling of incomplete evacuation -Treatment depends on the stage of the disease

Patient Education for the Patient with Inflammatory Bowel Disease

-Understanding of disease process -Nutrition and diet -Medications -Information sources: National Foundation for Ileitis and Colitis -Ileostomy care if applicable

Patient Learning Needs for Malabsorption

-Vitamin replacement -Dietary therapy -Probiotics -Consider fluid and electrolyte imbalance -Risk of osteoporosis