Management of Patients With Intestinal and Rectal Disorders

Basic Anatomy of Intestines

• • Small Intestine – 3 regions: duodenum, jejunum, ileum Large Intestine – Cecum, appendix, colon, rectum, anal canal – Appendix is attached to the cecum

Basic Anatomy of Intestines

Basic Anatomy of Intestines

Basic Anatomy of Intestines

Basic Anatomy of Intestines

Basic Anatomy of Intestines

Bowel Elimination

• • • • • Feces moved by peristalsis Defecation reflex Sigmoid colon contracts Anal sphincter relaxes Valsalva maneuver expels feces

Topics to Consider for Health History of a Problem Bowel • • • • • • • • • • Onset of problem Characteristics and course Severity Precipitating and relieving factors Cramping Bleeding increased constipation Recent travel outside the U.S.

Any changes in activities of daily living Diarrhea Constipation

Physical Assessment of Bowel Integrity and Function

• • • • • Auscultation of bowel sounds Rectal exam Anal exam Exam of stool Palpation (do last)

Altered Intestinal Function

• • • • Abdominal Assessment Inguinal Assessment Perianal Assessment Fecal Assessment

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 intra-abdominal 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.

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

Complications

• • • • • Hypertension Fecal impaction Hemorrhoids Fissures Megacolon

Diagnostic Findings

• • • • • • Pt Hx Physical examination Barium enema or sigmiodscopy (to id is it from spasm or narrowing of the bowel) Anorectal manometry ( to id malfunction of the sphincter) Defecography Pelvic floor MRI

Bowel Disorder Medications

• Laxatives – – Fibercon, Bran, Citrucel, Metamucil Nursing Responsibilities • • Mix agent with at least 6 oz of water just prior to administering Do not administer to clients with possible stool impaction or obstruction – Client and Family Teaching • • • Client should drink at least 6-8 glasses of fluid daily Agents may be mixed with fruit juice, water or milk Do not take at bedtime

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)

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.

Manifestations

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

Bowel Disorder Medications

• Antidiarrheal Medications – Kaopectate, Donnagel, Pepto-Bismol – Nursing Responsibilities • Administer on empty stomach • Assess for potential contraindications – Client and Family Teaching • Do not use for more than one week unless specified • Take in the morning

Complications

• • • Fluid and electrolyte imbalances Dehydration Cardiac dysrhythmias

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)

Selected Diets

• • Diarrhea – Oral fluids, glucose electrolyte balanced (Gatorade, Pedialyte) for bowel rest – Soft foods after 24 hours – Add milk products and fat last Constipation – High fiber (vegetable, raw fruits) to bulk up the stool mass – Reduce intake of refined foods and meats

Inflammatory Bowel Syndrome (IBS)

• • • • Functional disorders of intestinal motility No known cause, usually hereditary factor, psychological stress, depression and anxiety, diet high in fat and stimulating or irritating food, alcohol consumption and smoking.

More common in women than in men In it the peristaltic waves are affected at specific segments & the intensity of propel the fecal pattern, no evidence of inflammation or tissue changes in intestinal mucosa

• • • • • C\M: Alteration in bowel pattern (primary symptoms) constipation or diarrhea or mixing of both, abdominal pain ( ↑ with eating & ↓ with defecation) , bloating, abd distension Diagnosis: Stool studies, contrast X-ray, Barium enema, colonoscopy, proctoscopy, manometry, electromyography Medical management: Restrict food and then reintroduction of foods is important to determine type of food that is irritating (beans, caffeinated products, fried food, alcohol, spicy food) Stress reduction techniques Manage diarrhea and constipation

• Nursing management: Nurse should educate family and patient about the importance of good dietary habits, chewing food slowly and eat regularly, not taking fluid with meal since it may cause abd destination, discouraged alcohol and smoking.

Selected Diets

• • • IBS – May benefit from high fiber diet – Adding bran and fluid reduces incidence of loose diarrheal stools and constipated stools Gluten Free Diet: prescribed for clients with sprue Low Residue Diet: for clients with ileostomies and colostomies to prevent blockage.

Diarrhea, Constipation, IBS, and Fecal Incontinence

• Fecal Incontinence – Loss of voluntary control of defecation – Contributing factors included both physiologic and psychologic – Diagnosis based on client history and physical examination of the pelvic floor and anus to evaluate muscle tone – Nursing care includes bowel training programs and other measures to manage fecal incontinence

Appendicitis: - Appendix is a small, finger-like structure within the abd, about 10 cm long and attached to the cecum just below the ileocecal valve - fills with food and empties into the cecum - It is prone to obstruction and to infection (appendicitis) - Common cause of acute abd, and emergency abdominal surgery - Occur in all ages but it common between age 10-30 years

Bowel Disorders

• C\M: - vague epigastric pain or periumblical pain that progress to the RLQ - associated with low grade fever, N & V - loss of appetite - Localized tenderness at the Mc Burney’s point ( point between the umbilicus and the anterior superior iliac spine - positive rebound tenderness & rovsing sign - If it rupture pain become more diffuse, with the development of abdominal distention - Constipation may occur, so pt not given laxative

• Medical management: - Immediate surgery (Appendectomy) - AB pre op • - If it perforated drainage is applied to the abscess, then appendectomy is performed Nursing management: - Relive pain - Prevent FVD - Reduce anxiety - Prepare the pt for surgery - After surgery place pt in high fowler position or supine with leg slightly flexed

- Give pt opioid analgesic - Give food as tolerated - Teach pt wound care • - Instruct pt that he can resume normal physical activity within 2-4wk’

Nursing interventions for patient with complications after appendectomy:

- Peritonitis: observe for abd tenderness, fever, vomiting, abd rigidity and tachycardia, employ constant NG tube, correct dehydration, administer antibiotic Pelvic abscess: evaluate N & V, chills, fever, diaphoresis, diarrhea, prepare patient for rectal exam and surgical drainage, - Subphrenic abscess (under the diaphragm): evaluate for chills and fever, prepare x-ray exam, prepare patient for surgical drainage of abscess. - ileus: assess for bowel sounds, employ NG tube and suction, replace F& E, prepare for surgery

• Peritonitis: - An inflammation of the peritoneum, the serous membrane lining the abd cavity and covering the viscera.

- Results from bacteria (E.Coli, klebsiella, Proteus& pseudomonas) or MO from GI disease, in women it occur from disease of reproductive organ. It can result from trauma or injury (gunshot, stab wound) or kidney inflammation. - Other common causes are: appendicitis, perforated ulcer, diverticulitis and bowel perforation, peritoneal dialysis

• C\M: - Diffuse pain (constant, localized, more intense near the site of inflammation) - Tenderness and distention in the affected area - Rebound tenderness & paralytic ileus - N&V, increase temp (37.8- 38.3), increase pulse rate - Diminished peristaltic movement - Rigid abdominal muscle - Pain diminished in pt with diabetes (advanced neuropathy, liver cirrhosis and on analgesic or corticosteroids

Intestinal Obstructions

• • • • Mechanical obstruction Functional obstruction Small bowel Large bowel

Causes of Intestinal Obstructions

Bowel Disorders

Colostomy

• • • Is the surgical creation of an opening into the colon , allows the drainage of colon content to the out side the body. It could be temporary or permanent fecal diversion.

The consistency of the drainage is related to the placement of the colostomy.

Indications : Large bowel obstruction, Colorectal cancer. The colostomy begins to function 3- 6 days after surgery.

Ileostomy

• • • Ileostomy: the surgical creation of an opening into the ileum or small intestine, is commonly performed after a total colectomy. It allows for drainage of fecal matter from ileum to the out side of the body The drainage is liquid to unformed and occurs at frequent intervals.

Indication: chronic inflammatory bowel disease.

Colorectal Cancer

• • • • • The third most common cause of cancer deaths in the United States.

Risk factors (see Chart 38-8).

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 upon the stage of the disease.

Areas Where Cancer Can Occur

Placement of Colostomies

Anorectal Conditions

• • • • • Anorectal abscess Anal fistula Anal fissure Hemorrhoids Pilonidal sinus or cyst

• • Diseases of the Anorectum Includes: Anorectal abscess, Anal fistula, Anal fissure, hemorrhoids, pilonidal sinus or cysts. Anal fissure: - Is a longitudinal tear or ulceration in the lining of the anal canal - Causes: stress and anxiety (constipation), childbirth, overuse of laxative trauma, persistent tightening of the anal canal from - C\M: painful defecation, burning and bleeding during defecation, bright red on the paper toilet - Rx: dietary modification ( fiber supplement), stool softener, increase water intake, sitz bath, suppositories with analgesic, surgery ( lateral internal shpinctretomy with fissure excision)

Hemorrhoids - Dilated veins in the anal canal - 50 % of people above 50y of age develop hemorrhoids.

- Shearing effect on the anal mucosa during defecation leading to sliding of the anal structure ( hemorrhoidal and vascular tissue) - Pregnancy may initiate it due to the pressure in the hemorrhoidal tissue - Classifies as: internal or external - S&S: pain, itching, bright red bleeding with defecation - External: associated with sever pain from inflammation and edema caused by thrombosis lead to ischemia and necrosis. - Internal is not painful until they bleed or prolapsed when they enlarge

Anal Lesions

Bowel Disorders

Pilonidal Sinus

• • • • • • Management: avoid strain, hygiene, high-fiber diet, fruit, bran and fluid intake. Analgesic, bulk-forming agents such as (Metamucil),, warm compresses, sitz bath, bed rest allow the engorgement to subside. None surgical treatment: infrared photocoagulation, bipolar diathermy, laser therapy (to affix the mucosa to underling muscle) . Surgical treatment: rubber-band Ligation procedure after anoscope. Can be painful and may cause secondary hemorrhage or infection.

Cryosurgical hemorrhoidectomy: freezing the hemorrhoid for sufficient time to cause necrosis, painless, foul smelling, prolonged healing, not very common. For hemorrhoids with thrombosed vein hemorrhoidectomy is performed, after surgery small tube inserted through the sphincter to permit flatus and blood drainage

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

• • • •

Nursing Process: The Care of the Patient

•

with an Anorectal Condition—Diagnoses

Constipation Anxiety Acute pain Urinary retention Risk for ineffective therapeutic regimen management

Collaborative Problems/Potential Complications

• Hemorrhage

• 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.

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