Chapter 46: Caring for Clients with disorders of the lower GI tract

lower GI tract includes

Small and large intestines from the duodenum to the anus Material that moves down the lower G.I. tract consists of food residues, microorganisms, digestive secretions, and mucus Mixture of the substances composes feces

Normal bowel patterns

3 bowel movements/day - 3 bowel movements/week

first line treatment for IBDda

5-ASA drugs contain salicylate, which is bonded to a carrying agent that allows the drug to be absorbed in the intestine these drugs work by decreasing the inflammatory response

Constipation

A condition in which stool becomes dry, compact, and the difficult and painful to pass Fewer than three bowel movements a week for several weeks is often the defining factor for a diagnosis of chronic constipation

Diagnostic findings of constipation

A thorough history and physical exam are necessary to determine the underlying causes and need for further diagnostic testing treatment is based on findings of the history and physical exam, precluding the need for a more aggressive approach ABDOMINAL RADIOGARPHY helps determine the extent of the constipation BARIUM ENEMA is performed if a structural abnormality is supsepcted DEFECOGRAPHY, a thick barium paste is inserted into the rectum; X rays are taken as the client expels the barium to determine whether there are any anatomic abnormalities or problems with the muscles surrounding the anal sphincter ANORECTAL/COLONIC MOTILITY studies may be performed to confirm a motility disorder these studies use flexible catheters with sensors that measure the pressure of muscle contractions COLONIC TRANSIT/MARKER STUDIES are used to determine how long it takes for food to travel through the intestines. for 1/more days, clients swallow capsules that contain radiographically visible plastic particles after 5-7 days, X-rays are taken to determine whether any particles are left and if so, where they are the location of the particles can help determine whether there is colonic inertia related to muscle/nerve impairment or pelvic floor dysfunction SIGMOIDOSCOPY/COLONOSCOPY may be ordered to examine the sigmoid colon or the entire colon to determine if there are any issues

Medical treatment for ulcerative colitis

Aims toward achieving and maintaining remission The diet is kept as normal as possible but modified to increase caloric and nutritional content Client is instructed temporarily to refrain from eating foods associated with discomfort If all food cause discomfort, the symptoms are likely from the disease itself and not the food The client may be given TPN and intermittent lipid infusions to rest the bowel completely Blood transfusions and Iron are given to correct anemia The client may also need parenteral fluids and electrolytes Because frequent bowel movements interfere with the absorption of nutrients, supplementary vitamins are prescribed

Other possible contributing factors to somebody getting Crohn's disease

Allergic and auto immune responses triggered by diet or infectious microbial antigens Recurrent attacks on the tissue are believed to result from an exaggerated immune response, which explains the chronic nature of the disease The role of stress in the development of symptoms it Is believed to be a contributing factor but not a cause Stress may influence the clients ability to cope with symptoms

Fulminant colitis

Also affecting the entire colon Is a progression of severity of the ulcerations, with severe pain, copious diarrhea, and potential dehydration and shock

Diagnostic findings of Crohn's disease

And examination of stool specimens reveals steatorrhea or excessive fat and occult blood and white blood cells Results of blood studies indicate anemia from chronic blood loss and nutritional deficiencies White blood cell count and erythrocyte sedimentation rate may be elevated, confirming an inflammatory disorder Serum protein and albumin levels maybe low because of malnutrition Low serum levels of the fat soluble vitamins also reflect the clients malnourished state Abnormal serum electrolyte levels offended disturbed acid base balance Mail company severe diarrhea Serologic tests for IBD maybe helpful in some cases Barium enema findings may show inflammation in the large intestine, but the confirmation of the diagnosis requires an endoscopic examination (colonoscopy or sigmoidoscopy) Endoscopic evaluation allows for identification of Mucosal abnormalities (ex: skin lesions, ulcerations, cobblestone appearance, bowel Wall thickening, presents of fistula tracks) Biopsies taken during colonoscopy or sigmoidoscopy are examined under the microscope four evidence of chronic inflammation possible GRANULOMA (aggregate of inflammatory cells and when identified on biopsy confirms a diagnosis of Crohn's disease) The absence of granuloma does not rule out the diagnosis of Crohn's disease Clients with Crohn's disease are vulnerable to intestinal perforation doing barium enema and endoscopy because of poor integrity of the bowel Wall, they are monitored accordingly The further examination is needed a double balloon endoscopy maybe performed, using a longer scope for examination of the small intestine CT scans will also be done

What are acute abdominal inflammatory disorders

Appendicitis Peritonitis

Precautions when assessing the client for appendicitis

Avoid multiple or frequent palpation of the abdomen---there is danger of causing the appendix to rupture Perform the test for rebound tenderness at the end of the examination. The positive response causes pain and muscle spasm and makes makes it difficult to complete the rest of the assessment Do not administer laxatives or enemas to a client who is experiencing fever, nausea, and abdominal pain, even though the client may complain a Feeling constipated Laxatives and cathartics make causes appendix to rupture

Other places fistula can form

Between the rectum and vagina and women as evidenced by passage of stool from the vagina

Assessment findings of constipation

Bowel examination is irregular Clients describe feeling bloated Abdomen may be distended and bowel sounds maybe hypoactive Client experiences rectal fullness, pressure, and pain when attempting to eliminate stool What the patient passes usually is hard and dry Rectal bleeding may results as the tissue stretches and tears while the person tries to pass the hard, dry stool When a nurse inserts his glove and he lubricated finger in the rectum, the stool may feel like small rocks a condition referred to as SCYBALA Sometimes if the constipation has lasted for a long time the client may begin passing liquid stools around an obstructive stool mass (ENCOPRESIS), a phenomenon sometimes confused as diarrhea The liquid stool results from dry stool stimulating nerve endings in the lower colon and rectum, which increases peristalsis

Most common problems in the lower G.I. tract

Constipation Diarrhea

Diagnostic findings of Crohn's disease

Endoscopic examination shows inflamed areas alternating with healthy tissue The inflamed areas occur randomly, a phenomenon described as SKIP LESIONS The bowel is described as having a cobblestone appearance because of the deep ulcerations that form amid the edematous tissue longitudinal and transverse manner Diarrhea as a response to anxiety may be confused with exacerbation of the disease

Nursing management of IBD

Health history assists in determining the onset, duration, and nature of the clients G.I. problems Medical, drug, allergy, diet histories are all important Focuses on monitoring the client for complications, managing fluid and nutritional replacement, supporting the client emotionally, and teaching them about diet and medications The nurse determines the average number of stools the client passes each day and their appearance Providing regular skincare to avoid breakdown is essential Ask the client about weight loss and whether any foods increase the frequency of the bowel movements or cause discomfort Require assistance to maintain adequate nutritional intake Monitors the clients intake and collaborate with the dietitian to replace uneaten food with something more acceptable Physical examination includes auscultating and lightly palpating the abdomen and inspecting the rectal area Take a vital signs, weigh The Client, Measure and document intake and output Advise the client to report whenever a bowel movement occurs and it is important so it could be inspected and a sample sent to the lab for analysis Comply with special dietary modifications and understand the compliance with these it Is important Know everything about the prescribed drugs know everything about the prescribed drugs Use medications to control symptoms Riley thank you for the disease No signs to report immediately to the physician such as more frequent bowel movements, Extreme fatigue, severe abdominal pain, visible blood in the stool, adverse drug effects, or a way to loss

Dietary approach somebody with IBD

High fiber maybe indicated when it is desirable to add bulk to loose stools Low fiber diet may be indicated in cases of severe inflammation or stricture Hi calorie and high protein diet helps replace nutritional losses from chronic diarrhea Client may need a nutritional supplements depending on the area of the bowel affected When the small intestine is inflamed, some clients experienced lactose intolerance, requiring the avoidance of lactose rich Foods Some clients need to Elemental diet, such as Tolerex, Vivonex, or Peptamen, that's reduces proteins, fats, and carbs two an easily absorbed form Newly introduced polymeric diets (Modulen) may provide the benefits of inducing remission and are more palatable

Systemic disorders that predispose clients to constipation

Hyperthyroidism Diabetes pheochromocytoma porphyria hyercalcemia (resulting from hyperparathyroidism and excessive production of vitamin D)

Appendicitis

Inflammation of a narrow, blind protrusion called the vermiform appendix located at the tip of the cecum and it just below the ileocecal valve and the right lower quadrant of the abdomen Can occur at any age but most common in adolescents and young adults Difficult to diagnose at it' s onset because the initial symptoms resemble a host of other disorders such as gastroenteritis, crohn's disease, ovarian cyst, tubal pregnancy, and inflammation of the kidney or ureter

fistula

Inflammatory channels containing blood, mucus, pus, or stool 2/more are referred to as fistulae

constipation results from:

Insufficient dietary fiber and water Ignoring or resisting the urge to defecate Emotional stress Use of drugs that tend to slow intestinal motility Inactivity May stem from several disorders, either in the G.I. tract or systematically Chronic use of laxatives because such use can cause a loss of normal colonic motility and intestinal tone Chronic lead poisoning or concurrent medications such as opioids, tranquilizers, antidepressants, and antihypertensives Older adults are more prone to constipation because they take more drugs that can interfere with bowel elimination, have more chronic illnesses, and may have decreased mobility

Assessment findings of Crohn's disease

Known for periods of remission and exacerbation Onset is insidious and the course of the disease varies Most clients have abdominal pain, distention, and tenderness in the lower abdominal quadrants, especially on the right side Pain may be associated with eating, so clients stop eating and failed to ingest required nutrition, resulting in weight-loss Client may have a chronic history diarrhea and fatigue Growth failure is a common early symptom in adolescents Fever may be present As Crohn's disease progresses, anorexia, more weight loss, dehydration, and signs of nutritional deficiencies occur

fistulae

May form channel between the bowel and the skin surface (enterocutaneous fistulae)

2 international sets of criteria used to diagnose IBS

Rome set of criteria the manning criteria likelihood of IBS increases with signs and symptoms associated with the above 2

Drug therapy for ulcerative colitis

Medications used to treat Crohn's disease are also used to treat ulcerative colitis Corticosteroids, given orally, intravenously, or rectally are used if the disease does not respond to other measures Because of unacceptable side effects associated with long-term use of corticosteroids, the dose is tapered and it discontinued according to the clients response When tapering corticosteroids without exacerbating the disease becomes impossible, immunomodulating agents (azathioprine, 6-MP) are used to decrease the immune response and allow tapering GOALS OF THERAPY: induce and retain remission, allow the client to be as healthy as possible when contemplating the elective surgery

patho and etiology of crohn's disease

Most commonly occurs in the distal ileum and less commonly in the ascending colon the mucosa initially thickens and it is edematous, with ulcers forming in the inflamed areas the chronic inflammation in crohns disease extends through the submucosal layer; a transmural the Inflammatory process and because of that inflammation can extend beyond the lining of the bowel Inflammatory channels containing blood, mucus, pus, or stool (FISTULA) may develop Chronic inflammation in Crohn's disease also may lead to scarring and stricture formation and eventual obstruction of the lumen Transportation of digestive products is impeded, leading to abdominal pain

patho and etiology of ulcerative colitis

Multiple factors trigger ulcerative colitis including genetic predisposition, infection, allergy, and abnormal immune response The connection between the disease and a malfunction of the immune system is supported by the fact that clients with ulcerative colitis I have other coexisting immune related disorders such as ankylosing spondylitis and other manifestations Inflammation usually begins in the rectum and it extends proximately and continuously No healthy tissue appears between inflamed areas, as in Crohn's disease

Pathophysiology and etiology of constipation

Normally fecal matter collection the rectum and presses on the internal anal sphincter, creating an urge to defecate Peristalsis and distention of the colon facilitate the signal to release stool The gastrocolic reflex facilitates stool passage by accelerating peristalsis This reflex is most active after eating, particularly after the first meal of the day

Nursing management for ulcerative colitis

Obtain a health history to identify the nature of abdominal pain, Number and frequency of stools, anorexia, and weight loss Ask client about dietary patterns, including the daily amounts of alcohol and caffeine Auscultate the abdomen for bowel sounds and it characteristics Palpate the abdomen to determine any pain or tenderness Question radio graphic and endoscopic protocols for harsh laxatives and cleansing enemas when the client is experiencing severe diarrhea, because bowel irritation and stimulation tend to aggravated the clients symptoms if antispasmodics and opiates are prescribed, the nurse must exercise great caution when administering them because they may trigger the development of toxic megacolon report any sudden onset of abdominal distention, severe pain, or fever and apply it with a acute alternative colitis Observed the client receiving steroids for subtle changes because of these drugs mask inflammatory symptoms accompanying complications The dosage and frequency of steroids we Gradually are tapered when clients no longer need them Clients were discharged and need high levels of care, such as enteral feedings or TPN, require extensive teaching specific to their homecare needs Thoroughly cover all technical procedures for the client or significant other to perform and allow time for the client or caregiver to perform them with the nursing supervision before discharge Make a referral to homecare agency to provide continuity of care and to ease the transition from acute-care to homecare

During physical exam of Crohn's disease

Palpation may reveal abdominal mass Inspection of the perineum and perianal areas may reveal scars from previous fissures, skin tags, or evidence of fistulae or perianal absences

For clients with chronic constipation the underlying causes it Includes the following

Partial or complete blockage in the colon or rectum Neurologic factors related to neuropathy or a neurologic disorder such as multiple sclerosis Muscular disorders that interfere with the normal contraction and relaxation of the muscles in and around the pelvis Hormonal conditions such as diabetes may lead to constipation Impaired G.I. motility

Colectomy

Partial or complete surgical removal of the colon for toxic megacolon for perforation

Common sites for enterocutaneous fistulae

Perianal sites Perilabial sites Inflammation also may extend between the bowel and other pelvic organs (ex: vagina), between the bowel and bladder, or between loops of bowel (enteroenteric fistulae, enterovaginal, enterovesical)

Elemental diet

Reduces proteins fats and carbs to and easily absorbed form Include remission in Crohn's disease without medications Not able to eat or drink normally while on the diet making this unacceptable for many Not a very palatable, some may need to be administered through an G-tube Success with this diet requires extensive education and clients motivation

ENCOPRESIS

Sometimes if the constipation has lasted for a long time the client may begin passing liquid stools around an obstructive stool mass (ENCOPRESIS), a phenomenon sometimes confused as diarrhea The liquid stool results from dry stool stimulating nerve endings in the lower colon and rectum, which increases peristalsis The increased peristalsis sends watery feces from higher in the bowel than the retained stool this symptom is most common in residents of nursing homes and school aged children who have long standing history of constipation, stool withholding behavior, or both it may be necessary to check for fecal impaction

Anatomic disorders of the colon, rectum, and anus which predispose a person of constipation include

Strictures (ex: secondary to disease or intestinal resection) Anal stenosis Anterior displacement of the anus

Drug therapy for IBD

Supplementary vitamins, Iron, antidiarrheal and anti peristaltic drugs to reduce peristalsis and the rest of the bowel Anti-inflammatory corticosteroids and 5-aminosalicylic (5-ASA) medications, immune-modulating agents, antibiotics Vitamin and iron supplements are used for known deficiencies and malabsorption Antidiarrheal agents such as lomotil and immodium usually are used sparingly and only when clients don't have an infection Corticosteroids (prednisone) are used to during acute exacerbations of symptoms and when 5-ASA drugs cannot control the symptoms Hydrocortisone is available in an email form and is effective in controlling distal disease without posing the high-risk of systemic side effects Long term cortical steroid use as undesirable because of the potentially severe side effectsf

Surgical management for ulcerative colitis

Surgery is necessary when the disease does not respond to medical treatment or with complications such as dysplastic tissue (precancerous condition), perforated colon, or hemorrhage Removal of the colon under elective, nonemergent circumstances offers the client the best possible outcome and is the definitive cure The current standard treatment is ileoanal pull through and anastomosis This procedure is performed in 2 stages, several weeks apart In the first stage, the colon is removed and a rectal pouch is created from a section of the ileum; the rectal mucosa is removed to create a temporary ileostomy In the second stage the surgeon closes the ileostomy and connects the intestine to the rectum, allowing the client to defecate normally On an emergency colectomy is performed, and anastomosis may be impossible, necessating creation of a permanent ileostomy

Surgical management of IBD

Surgical treatment it Is reserved for complications such as intestinal obstruction, perforation, or fistula formation The need for surgical intervention it Is common in Crohn's disease 75% of clients with Crohn's disease require surgery within 20 years of the onset on the symptoms 90% require surgery within 30 years Unlike surgical treatment for ulcerative colitis, removing that inflamed portion of the intestine does not alter disease progression or recurrence Many clients who undergo surgery for Crohn's disease require additional surgery within a few years An intestinal transplant, a new approach to surgical intervention for clients with Crohn's disease, maybe performed on the clients who have lost intestinal function The procedure does not providing cure but it does improve the client's quality-of-life Surgical removal of a large amount of intestine results in the loss of absorptive surface called SHORT BOWEL SYNDROME call Massive bowel resection results on dependence of TPN possibly for life Removal of the colon requires a permanent the ileostomy because the disease tends to recur and any rectal pouch

Extra-intestinal manifestations of IBD

Systemic nature of this disease is evidenced by symptoms outside the G.I. tract referred to as Arthritis, Arthralgias Skin lesions Inflammation of the eyes (uveitis , conjunctivitis, iritis) Disorders of the liver and gallbladder

stool consistency

The consistency of stools and the comfort with which a person passes them are more reliable indicators from abnormal or normal bowel patterns, than amount of times The type and amount of food a person consumes greatly affects stool consistency High fiber diets (ex: whole grains, fresh fruits, uncooked vegetables) form an increased residual of cellulose, an insoluble, indigestible product, in the bowel Cellulose absorbs water The combination of cellulose and water increases and softens fecal volume, which speeds the passage of feces through the lower G.I. tract

positive rovsing sign

when an examiner reply palpates the left lower abdominal quadrant and the client feels pain in the RLQ, this is refereed to as POSITIVE ROVSING'S SIGN and suggests acute appendicitis when assessing a client with appendicitis, the nurse should palpate the left lower quadrant to elicit a rovsing's sign. this causes pain to be felt in the right lower quadrant

Assessment findings of ulcerative colitis

The onset of the disease usually is abrupt Clients experiences severe diarrhea and expel blood, pus, mucus, and fecal matter Cramps and abdominal pain in the lower left quadrant the accompany diarrhea Eating precipitates cramping and diarrhea, resulting in anorexia and fatigue and dehydration Clients usually experience wait loss The urge to defecate may I'm so suddenly and with such urgency that the client is incontinent Some clients experiencing incontinence during sleep Clients may spell very little stool, or they may have 10-20 stools per day This disease is usually marked by exacerbations and remissions

Serologic tests

These tests allow for the identification of certain antibodies common to those with Crohn's disease and those with ulcerative colitis These tests do not confirm IBD because clients w/ IBD may not test positive for the antibodies, and some clients who do not have IBD may test positive

Medical management of IBD

Treatment is supportive Diets TPN may become necessary to provide intestinal rest IV fluids, electrolytes, and whole blood are given to correct anemia and restore fluid and electrolyte balance

diagnostic findings of appendicitis

WBC count elevated, revealing moderate leukocytosis when a differential count of leukocytes is performed, it shows an ever increasing number of immature neutrophils, indicating progressive worsening of the inflammatory condition a CT scan or abdominal ultrasound shows enlargement at the cecum

Pancolitis

When to clients entire colon his affected with ulcerative colitis, and here she experiences severe bouts of bloody diarrhea, pain, cramps, fatigue, and weight loss

medical and surgical management of peritonitis

a NG tube is used to relieve abdominal distention by suctioning the accumulated gas and stagnant upper GI fluids IV fluids and electrolytes replace substances related in the peritoneal cavity and lost through vomiting and drainage from gastric intubation large doses of antibiotics are prescribed to combat infection analgesics such as meperidine (Demerol) or IV morphine sulfate are ordered to relive pain and promote rest antiemetics are prescribed for N/V the perforation is surgically closed so that intestinal contents can no longer escape

Toxic megacolon

a complication in which the colon dilates and becomes atonic (lacks motility)

when diarrhea persists and stools are frequent and large, or if the person is very young, an older adult, or debilitated, medical treatment may include one or more of the following measures:

administration of an antidiarrheal agent such as diphenoxylate hydrochloride with atropine sulfate (lomotil), loperamide hydrochloride (Imodium), or a combo product such as kaolin and pectin (Kaopectate) fluid and electrolyte replacement by either the oral or IV route dietary adjustments, which may involve eliminating foods that cause diarrhea TPN if diarrhea is severe and prolonged and if the introduction of oral fluid and food results in another episode of diarrhea

irritable bowel syndrome

aka spastic bowel functional motility disorder primarily affecting the colon motility problem in which constipation and diarrhea are alternately present; either diarrhea/constipation predominates refers to a cluster of symptoms that occur despite the absence of an identifiable disease process people with this experience abdominal pain and cramping, bloating and flatus, as well as diarrhea/constipation with or without the presence of mucus doesn't cause inflammation of the bowel or changes in bowel tissue, and it doesn't increase the risk of colorectal cancer women are affected more than men people younger than 45 y/o are more likely to be diagnosed a family history of IBS places clients at an increased risk for developing IBS

McBurney's point

an area midway btw the umbilicus and the R iliac crest

assessment findings of appendiciits

an attack of abdominal pain is the most frequent symptom at first the pain is generalized throughout the abdomen or around the umbilicus later, the pain localizes in the RLQ at McBurney's point pain is worse when manual pressure near the region is suddenly released, a condition called REBOUND TENDERNESS when an examiner reply palpates the left lower abdominal quadrant and the client feels pain in the RLQ, this is refereed to as POSITIVE ROVSING'S SIGN and suggests acute appendicitis low-grade fever and N/V may be present the abdomen is tense and the client usually flexes the right hip to relieve discomfort the position of the appendix influences the type of pain (ex: clients may have pain with defecation if the appendix is against the rectum. if the appendix circles toward the cecum, clients may complain of lumbar pain and tenderness) clients can have pain with urination if the tip is pressing narthex bladder or a ureter) if the appendix perforates, clients experience more diffuse abdominal pain the abdomen appears distended secondary to a PARALYTIC ILEUS (intestine lacks peristalsis) perforation generally occurs 24 hours after the onset of abdominal pain clients have a fever of 37.7 C (100 F) or higher are very ill

medical and surgical management of appendciitis

antibiotics are given and the client is restricted from eating or drinking while a decision is made about surgery IV fluids are prescribed to meet the clients fluid needs analgesics may be withheld initially to avoid masking symptoms that may affect the diagnosis if the symptoms worsen the surgeon performs an APPENDECTOMY, either via several small laparaospic incisions or as an open incision procedure to remove the appendix before it spontaneously ruptures the appendix has no known function in the body it removal results in cure with no physiologic changes if the appendix perforates or ruptures, an abscess or peritonitis can develop open appendectomy will then be performed to allow for a thorough cleaning of the abdominal cavity some complications may occur which can include wound infection or abscess formation at the site where the appendix was removed or at the site of the surgical incisions rarely are there any issues with an ileum or peritonitis, but with any abdominal surgery this is a potential risk

nursing management of appendicitis

assess vital signs and the clients pain to detect early changes in the symptoms if ordered, administer IV fluid therapy and observe the client's response to antibiotics when analgesics are withheld, the nurse is empathetic and facilitates comfort with positioning, imagery, and distraction when surgery is indicated, preparing the client quickly is important to avoid delay that may cause surgical complications help client ambulate and try light nourishment convalescence may be rapid, although postoperatively progress depends on the clients age, general physical condition, and extent of complications a healthy young adult usually can return to normal activities soon clients need to avoid heavy lifting or unusual exertion

diarrhea may be related to

bacterial/viral infections affecting the intestine lactose intolerance fructose intolerance food allergies or intolerance artiifcal sweeteners such as sorbitol or mannitol (found in chewing gum and other artificially sweetened products) uremia intestinal disease such as diverticulitis, ulcerative colitis, malabsorption, or intestinal obstruction rapid addition of fiber to the diet consumption of highly spiced or seasoned food food poisoning overuse of laxatives adverse effects drugs escpially antibiotics or concentrated tube feeding formulas may be caused by surgical resection of large portions of the small bowel (SHORT BOWEL SYNDROME) immunoglobin A defieicny overeating concurrent medication (especially antibiotics) irritable bowel syndrome

inflammatory bowel disease

chronic illness characterized by exacerbations and remissions refers to several chronic digestive disorders believed to result from the immune system attacking the bowel unlike IBS, IBD doesn't resolve w/out medical intervention

ulcerative colitis

chronic inflammation of the colon with presence of ulcers Chronic inflammation usually is limited to the mucosal and submucosal layers of the colon and rectum The inflammation causes small ulcers to form that produces mucus and pus and resulted in bleeding The disease is common in young and middle aged adults but can occur at any age Some clients experience prolonged remission, where others experience mild to severe (potentially life-threatening) exacerbations of symptoms The lining of the colon tends to bleed easily ulceration may extend to the muscular layer of the bowel wall Superficial abscesses form in depressions and the mucosa Poor integrity of the bowel wall may lead to TOXIC MEGACOLON, a complication in which the colon dilates and becomes atonic (lacks motility) The thin bowel wall is vulnerable to perforation under these conditions, leading to peritonitis, septicemia, and the need for emergency surgical repair

ulcerative proctitis

chronic inflammation of the most distal area of the large intestine When inflammation extends beyond the sigmoid colon

Crohn's disease aka regional enteritis

chronic inflammatory condition can occur in any portion of the GI tract but affects the bowel the most in the terminal portion of the ileum begins in adolescence/young adulthood it can also occur in adults aged 50 or 60 y/o

assessment findings of IBS

clients experience various degrees of abdominal pain that defecation receives most clients with IBS describe having chronic constipation with sporadic bouts of diarrhea many clients suffer with belching and flatulence (intestinal gas) symptoms don't awaken people from sleep some clients with IBS report anxiety, insecurity, depression, or anger weight usually remains stable indicating that when diarrhea occurs, malabsorption of nutrients doesn't accompany it there often is white or yellow mucus in the stools and clients may report that they don't feel like there bowels completely empty with a bowel movement may experience urgency

paralytic ileus

complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction

most common inflammatory diseases that include IBD

crohn's disease ulcerative colitis the above disorders are grouped together because of their similar symptoms and treatments

3 major problems associated with diarrhea

dehydration electrolyte imbalances vitamin deficiencies

medical and surgical management of IBS

dietary changes reduce flatulence and abdominal discomfort by trail and error, the client eliminates common food sources that cause discomfort or intestinal gas, such as beans or cabbage at the same time a high fiber diet (30-40 g/day) or a bulk forming agent such as products containing psyllium (e.g. Metamucil), is prescribed to regulate bowel elimination the fiber draws water into constipated stool and adds bulk to watery stool an anticholinergic such as dicyclomine (Bentyl) has an antispasmodic effect if taken before meals either a prescription or nonprescription antidiarrheal is used for temporary relief from diarrhea antidepressant medications may be prescribed not only to help with depression but also to inhibit neuron activity that impacts intestinal motility

strategies to prevent constipation

eat a diet that includes fruits, vegetables, and grains high fiber diet (hundred percent whole wheat bread, whole wheat or bran cereal, oats, Brown rice, whole wheat pasta) Look for whole grain breads that contain at least 2 g of fiber per serving at whole grain cereals that provide at least 5 g of fiber per serving limit high fat meats and diary products limit sweets, which also can be high in fat drink fluids, especially water, and fluids that are sugar free engage in regular physical activity, including exercises that involve toning abdominal muscles don't ignore the urge to defecate try to establish a regular time for a bowel movement; generally best within 30 minutes of a meal

clients with IBS may also have the following recommendations

eliminate alcohol stop smoking participate in stress management strategies, such as regular exercise and/or relaxation techniques engage in counseling if depression or anxiety worsens

those who are prone to crohn's disease

family history of the disease those who are white with a European and/or jewish ancestry those who smoke

patho and etiology of IBS

fluctuating intestinal motility tends to be an underlying factor that causes symptoms clients with IBS have stronger and longer intestinal contractions that can cause diarrhea or they experience just the opposite, with weaker contractions to propel digested food through the GI tract causing dry, hard stools and infrequent defecation affected clients appear to be overly sensitive to changes in the bowel such as the presence of food, gas or stool there may also be an imbalance or alteration of bacteria that are necessary for normal digestion other factors may also be involved such as certain foods, stress and anxiety, hormonal changes for women, infection/irritation, disturbances in vasculature of the bowel or metabolism

diarrhea

frequent passage of larger than normal amounts of liquid or semiliquid stool (more than 3 bowel movements/day and over 200 g/day) results from increased peristalsis, which moves fecal matter through the GI tract much more rapidly than normal the swift velocity causes intestinal cramping and decreases the time available for water to be absorbed from stool in the large intestine can be acute or chronic acute episodes are short lived lasting at most 7-14 days chronic diarrhea occurs for more than 2-3 weeks and can persist with periods of no diarrhea and then resumption of symptoms can occur when diarrhea results from a disease that causes malabsorption , the client is at risk for nutritional deficiency the sudden onset of acute abdominal pain or a rise in temperature may indicate perforation of the bowel

good sources of fiber

hundred percent whole wheat bread, whole wheat or bran cereal, oats, Brown rice, whole wheat pasta Seeds (sesame, sunflower, Poppy seeds) Nuts (crunchy peanut butter, popcorn)

signs of affected areas with crohn's disesae

hyperemia (increased blood supply) Edema Ulcerations

rome set of criteria

include abdominal pain for at least 3 days a month for atlas 3 months, accompanied by 2 of the following: relief of pain with defecation alteration in frequency of stools a change in the consistency of stool----either harder/softer

most common cause of diarrhea

infection by bacterial, parasitic or viral agents

peritonitis

inflammation of the peritoneum (membrane lining the abdominal cavity and surrounding the organs within it)

Treatment of moderate to severely active and fistulizing Crohn's disease is

infliximab (remicade), which has proved safe and effective in achieving and maintaining remission in many clients with Crohn's disease An antibody that interferes with the inflammatory process early in the immune response by inhibiting tumor necrosis factor adalimumab (Humira) is a similar medication used in clients for whom Remicade has not been effective Clients learn to self administer samara by sub Q injections every other week The potentially serious risk of infection, including TB, is associated with its use certolizumab pegol (Cimzia) also inhibits TNF Injections are given every other week initially and then monthly this is effective cimzia possesses a risk of infection because of its effect on the immune system

Diagnostic findings of ulcerative politeness

lab findings are similar to those described in the section on Crohn's disease shit BARIUM ENEMA reveals evidence of inflammation Definitive diagnosis requires proctosigmoidoscopy or colonoscopy with biopsy Endoscopic examination and biopsy of the lining of the colon reveals characteristic inflammatory lesions Biopsies of the intestinal mucosa reveal evidence of chronic inflammation These diagnostic studies usually are withheld in cases of toxic megacolon because of the high risk of perforation Clients have a clear liquid diet before the procedure and a gentle tap water enema on the day of examination

patho and etiology of appendicitis

like other parts of the bowel, the appendix fills with food and empties digested material regularly its location and shape contribute to the inefficiency of this process the inflammation begins when the opening of the appendix narrows or becomes obstructed the obstruction may result from a hard mass of feces, called a FECALITH, a foreign body; local edema; or tumor the blockage interferes with drainage of secretions from the appendix, and they accumulate in the confined space the appendix enlarges and distends and the swelling compresses surrounding blood vessels the locally damaged cells are then easily infected with bacteria from within the intestinal lumen unless the inflammation resolves, the appendix can become gangrenous or it ruptures, spilling bacteria throughout the peritoneal cavity

nursing management of peritonitis

monitors the acutely ill client while completing preparations for diagnostic tests or surgery administer analgesics and infuse IV fluids with secondary administrations of antibiotics if ordered, pass a NG tube and connect it to the suction client may need a urinary retention catheter assess the circulatory status by taking vital signs frequently and monitoring central venous and pulmonary artery pressures for the client who has had surgery, assess the clients vital signs, fluid balance, incision, dressing, and drains assess the clients pain level for clients who have prolonged recovery time, TPN may be initiated provide frequent explanations and emotional support client needs monitoring for continued abdominal infection if the client experiences abdominal distention, fever, changes in LOC, or deviations in vital signs, the nurse must notify the physician quickly

nursing management for clients with IBS

most clients with IBS aren't hospitalized nurses become involved in their care during diagnostic testing, follow up visits, or hospitalization for a concurrent problem during these encounters the nurse gathers a comprehensive database of symptoms, helps manage the problems associated with constipation and diarrhea, explains therapeutic treatments, evaluates the clients understanding of the regimen for self care, and monitors the response to therapy keep a diary in which they record daily food consumption and symptoms, clients can determine what foods can cause problems avoiding problem foods help alleviate symptoms eating at regular intervals helps many clients for clients with diarrhea, eating frequent small meals may be effective

intestinal obstruction

occurs when a blockage interferes with the normal progression of intestinal contents through the intestinal tract obstruction is more common in the small intestine than in other parts of the tract obstruction in the large intestine generally occurs in the sigmoid colon the causes are classified as mechanical or functional (aka paralytic ileum or pseudo-obstruction) and as partial or complete the severity depends on the region of the bowel affected, degree to which the lumen is obstructed and degree to which blood circulation to the intestine is impeded is extremely dangerous and may be fatal if not treated promptly

rebound tenderness

pain that increases when pressure (as from a hand) is removed

common causes of peritonitis

perforation of a peptic ulcer, the bowel, or the appendix abdominal trauma IBD ruptured ectopic pregnancy infection introduced during peritoneal dialysis a procedure used to treat kidney failure

radiographic studies of IBS

radiographic and endoscopic tests rule out other disorders with similar symptoms such as peptic ulcer disease, colorectal cancer, diverticulitis, or inflammatory bowel disease a barium enema and colonoscopy may show the spams, distention, and mucus accumulations associated with IBS

diagnostic findings of peritonitis

results of WBC count show marked leukocytosis abdominal X-rays reveal free air and fluid in the peritoneum a CT scan or ultrasonography identifies structural changes in abdominal organs cultures of peritoneal fluid and blood usually reveal bacteria such as Escherichia coli, Klebsiella, Proteus, and Pseudomonas if untreated, clients develop sepsis and septic shock, which if untreated can lead to death

diagnostic findings with diarrhea

routine stool cultures are obtained to identify bacterial infections as the cause for infectious diarrhea identifying parasites involves placing stool specimens in special preservative for analysis of parasites and their ova by the microbiology department several samples may be needed because parasites are not typically shed with each tool routine ova and parasite analysis may identify ameba infections CBC test and blood chemistries may be done, depending on symptoms and if a case of the diarrhea is not evident urinalysis may be done nurses typically test stool specimens, collecting a specimen from the client (FECAL OCCULT BLOOD TEST (FOBT) OR GUAIAC SMEAR TEST (gFBOT) PROCTOSIGMOIDOSCOPY/COLONOSCOPY may be performed to identify chronic inflammation or alteration in the mucosal layer of the large intestine these studies often are carried out to identify the cause of chronic inflammation an upper GI series with small bowel follow through allows for radiologic exam of the small bowel and identification of inflammation upper GI endoscopy allows for identification of malabsorption disorders such as celiac disease

symptoms of peritonitis

severe abdominal pain distention tenderness N/V anorexia diarrhea initially followed by inability to pass stool/gas fever may be absent initially, but the temperature rises as infection becomes established

IBD causes

severe diarrhea with pain weight loss chronic fatigiue

the manning criteria

similar to Rome set of criteria focus on relief of pain with defecation, incomplete emptying of the bowel w/each movement, the presence of mucus in the stools and changes in stool consistency

patho and physiology of peritonitis

spillage of chemical contents and bacteria inflames the peritoneum, which leads to localized abscess formation or generalized inflammation the intestinal tract initially responds with hypermoitltiy but eventually paralytic ileus ensues, with air and fluid trapped in the bowel the proliferation of bacteria leads to tissue edema and leakage of fluid fluid in the abdominal cavity has increasing amounts of bacteria, protein, blood, cellular debris, and WBC's a generalized peritonitis occurs, vascular fluid shifts to the abdomen, lowering BP and producing hypovolemic shock or septic shock if the condition is not treated promptly or adequately, death may follow

assessment findings with diarrhea

stools are watery and frequent in severe cases blood and mucus pass with the stool the client usually experiences urgency (TENESMUS) and abdominal discomfort bowel sounds are hyperactive skin around the anus may become excoriated from contact with fecal matter and products of the digestive process (ex: gastric acid, bile salts) fever may be present infectious diarrhea typically has a sudden onset, with accompanying generalized malaise

5-ASA drugs

sulfasalazine (Azulfidine); Folic acid acid is recommended for clients taking this drug, which interferes with the absorption of this nutrient olsalazine (Dipentum) melamine (Asacl,PEntasa) mesalamine also available in the enema or suppository form (Rowasa) and may be used to treat distal disease

appendectomy

surgical removal of the appendix if the symptoms worsen the surgeon performs an APPENDECTOMY, either via several small laparaospic incisions or as an open incision procedure to remove the appendix before it spontaneously ruptures

assessment findings of peritonitis

the client avoids moving the abdomen when reaching because movement increases pain he or she may draw the knees up toward the abdomen to lessen the pain lack of bowel motility typically accompanies peritonitis the abdomen feels rigid and birdlike as it distends with gas and intestinal contents bowel sounds typically are absent the pulse rate is elevated, and respirations are rapid and shallow if the peritonitis is unresolved, severe weakness, hypotension, and a drop in body temp occur as the client nears death

medical/surgical management of constipation

treating the cause provides the best relief for quick symptomatic relief, the physician prescribes an enema/laxative in oral or suppository form, followed by prophylactic administration of a stool softener fiber supplements, stimulants such as bisacodyl (Dulcolax) or Senna (Senokot), lubricants or stool softeners may be ordered dietary management also is promoted

medical and surgical management of diarrhea

treatment of diarrhea involves resting the bowel by limiting intake to clear liquids for 1 or 2 meals and gradually advancing to a regular diet chronic diarrhea depletes the bowel of helpful organisms and allows yeasts and fungi to thrive unchecked to recolonize the bowel, capsules or granules containing lactobacillus acidophilus (acid or lactinex) are prescirbed these agents are referred to as probiotics

Disorders of the lower G.I. tract usually affect

usually affect: Movement of feces towards anus Absorption of water and electrolytes Elimination of dietary wastes Usually manifests themselves as changes in bowel elimination