Transcript Lower Gastrointestinal Problems

Lower Gastrointestinal Problems
Zoya Minasyan
RN, MSN-Edu
Colorectal Cancer
• Third most common form of cancer
• More common in men
• Risk factors
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Family or personal history of colorectal cancer
Increased age
Colorectal polyps
Lifestyle factors
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Obesity
Smoking
Alcohol
Large amounts of red meat
Etiology and Pathophysiology
Tumors spread through the walls of the colon into musculature and into the lymphatic and
vascular system.
Etiology and Pathophysiology
• Most common sites of metastasis
– Regional lymph nodes
– Liver
– Lungs
– Bones
– Brain
• Usually nonspecific, do not appear until
advanced.
Diagnostic Studies
• Colonoscopy
– Entire colon is examined.
– Biopsies can be obtained.
– Polyps can be immediately removed and sent to the laboratory for
examination.
• Colonoscopy and tissue biopsies confirm diagnosis.
• Additional laboratory studies must be done.
– CBC
– Liver function tests
• CT scan or MRI in detecting
• Liver metastases
• Depth of penetration of tumor in bowel wall
• Surgical therapy
– Surgery is the only cure.
Inflammatory Bowel Disease
• Characterized by chronic, recurrent
inflammation of the intestinal tract
– Periods of remission interspersed and
exacerbation
• Ulcerative colitis: Inflammation and ulceration
of the colon and rectum
• Crohn’s disease: Inflammation of segments of
the GI tract
Acute Ulcerative Colitis
Comparison of distribution patterns of Crohn’s disease and ulcerative
colitis, as well as different conformations of ulcers and wall thickenings.
Ulcerative Colitis
Etiology and Pathophysiology
• Multiple abscesses develop in the intestinal
glands.
• Abscesses break through into the submucosa,
leaving ulcerations.
• Ulcerations destroy the mucosal epithelium,
causing bleeding and diarrhea.
• Fluid and electrolyte losses
• Protein loss
Crohn’s Disease Description
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A chronic, nonspecific inflammatory bowel disorder of unknown origin
Can affect any part of the GI tract from the mouth to the anus
Most often seen in the terminal ileum and colon
Inflammation involves all layers of the bowel wall.
Segments of normal bowel occurring between diseased portions
Ulcerations are deep and longitudinal.
Ulcerations penetrate between islands of inflamed edematous mucosa,
causing the classic cobblestone appearance.
• Narrowing of the lumen with stricture development
– May cause bowel obstruction
• Microscopic leaks can allow bowel contents into peritoneal cavity.
Peritonitis may develop.
• Abscesses or fistulous tracts that communicate with other loops of bowel,
skin, bladder, rectum, or vagina may occur.
Inflammatory Bowel Disease
Clinical Manifestations
• Chronic disorder with mild to severe acute exacerbations
• May occur at unpredictable intervals over many years
• Nonspecific complaints
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Diarrhea
Bloody stool
Fatigue
Abdominal pain
Weight loss
Fever
• Major symptoms
– Bloody diarrhea
– Abdominal pain
Crohn’s Disease
Clinical Manifestations
• Main manifestations
– Diarrhea
– abdominal pain
• Weight loss may occur if small intestine is
involved.
Inflammatory Bowel Disease
Complications
• Complications may be classified as
– Intestinal (localized to GI tract)
– Extraintestinal (systemic)
Ulcerative Colitis: Complications
• GI complications
– Hemorrhage
– Strictures
– Perforation (with possible peritonitis)
– Fistulae
– Toxic megacolon
• Dilation and paralysis of the colon
• Associated with perforation
• May need emergency colectomy
Crohn’s Disease: Complications
• Extraintestinal
– Thromboembolism
– Arthritis
– Eye inflammation
– Kidney stones
– Gallstones
– Skin lesions
Diagnostic Studies
• History and physical examination
• Blood studies
– CBC
– Serum electrolyte levels
– Serum protein levels
• Stool cultures
– Pus
– Blood
– Mucus
• Sigmoidoscopy and colonoscopy
– Biopsy specimens
• Double-contrast barium enema
• Capsule endoscopy
Collaborative Care
• Goals of treatment
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Rest the bowel.
Control inflammation.
Combat infection.
Correct malnutrition.
Alleviate stress.
Relieve symptoms.
Improve quality of life.
Drug therapy
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Aminosalicylates
Antimicrobials
Corticosteroids
Immunosuppressants
Biologic and targeted therapies
Irritable Bowel Syndrome (IBS)
Description
• Characterized by intermittent and recurrent abdominal pain and
stool pattern irregularities
• Symptoms
– Alternating diarrhea/constipation
– Abdominal distention
– Excessive flatulence
– Bloating
– Continual defecation urge, urgency
– Sensation of incomplete evacuation
– Fatigue
– Sleep disturbances
• Common in patients with IBS
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Anxiety, panic disorder
Depression
Posttraumatic stress disorder
Abuse history
Treatments
• Education and reassurance
• Relaxation
• Stress management techniques
• Alternative therapies
• Eliminate gas-producing foods.
– Brown beans
– Brussel sprouts, cabbage, cauliflower, raw onions
– Grapes, plums, raisins
– Determine if lactose intolerant.
Drug Therapy: Antispasmodics
• Anticholinergics
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Dicyclomine (Bentyl)
Reduce colonic motility after meals.
Take before meals.
Side effects
• Dry mouth, urinary retention, tachycardia
• Loperamide (Imodium)
– Decreases intestinal transit
– Enhances intestinal water absorption and sphincter tone
• 5-HT3 receptor blockers
– ↓ Urgency, pain, and diarrhea in diarrhea-prominent women
– Alosetron (Lotronex)
• FDA approved for women only
• Must be monitored because of potential side effects
Diarrhea
• Diarrhea is the passage of at least three loose
or liquid stools per day. It may be acute or
chronic, and is chronic if it lasts longer than 4
weeks
• Some organisms such as E. coli, Rotavirus,
Clostridium difficile, can impair the
absorption, damage the intestines directly or
produce toxins.
Constipation
• Normal BM frequency varies from 3 BM daily to
BM every 3 days
• Constipation is decrease in frequency of BM from
what is normal for the individual
• Common cause
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Insufficient diet fiber
Inadequate fluid intake
Decreased physical activity
Ignoring the defecation urge
Constipation and Diarrhea
• Constipation – bowel movements that are infrequent, hard or dry,
and difficult to pass.
• Diarrhea – increased number of loose liquid stools.
• Causes of Constipation:
- Frequent use of Laxatives
- Advance age
- Inadequate fluid intake
- Inadequate fiber intake
- Immobilization due to injury
- A sedentary lifestyle
• Causes of Diarrhea:
- Viral Gastroenteritis
- Overuse of laxatives/laxative abuse
- Use of certain antibiotics
- Inflammatory bowel disease (Cronh’s disease – subacute, chronic
inflammation extending throughout the entire intestinal mucosa
(Terminal Ileum).
Diagnostic Procedures
• Fecal Occult Blood Test ( OB) – fecal sample is obtained
using a medical aseptic technique and wearing disposable
gloves. e.g. Hemoccult slide test and record result.
Certain food like red meat, raw vegetable and medication
(aspirin, NSAIDS) can cause false positive. Bleeding can be a
sign of CANCER (others include anal fissures, hemorrhoids,
inflammatory bowel disease, malignant tumor, peptic
ulcer) which can be contributing factor to constipation.
An early sign of colon cancer is rectal bleeding. Encourage
client 50 years of age and older and those with increased
risk factor to be screen with FOBT yearly and Routine
Colonoscopy at 50.
Clinical Manifestation of GI Bleeding
• Pallor: conjunctiva, mucous membranes, nail beds,
Dark tarry stools ( Peptic Ulcer due to mixture
of gastric acid and the blood) Macroscopic
Bright –red (constipation, bleeding from
anal fissure or sigmoid area).
Abdominal mass or bruit
Decreased BP, rapid pulse, cool ext. (s/s of
shock)
• Stress can cause or exacerbate ULCERS. Teach client
on stress-reduction methods and encourage those
with family of ULCERS to obtain medical survillance
for ulcer formation.
Diagnostic Procedures
• Digital Rectal Examination – Checks for
impaction. Client position on the left side
with knee flex. Client V/S and response
should be monitored.
• Stool Cultures – obtaining fecal samples using
a medical aseptic technique. Specimen should
be labeled promptly sent to the laboratory.
Intestinal bacteria can be a contributing
factor for diarrhea.
Signs and Symptoms/Nursing Assessments
• Constipation:
- Abdominal bloating
- Abdominal cramping
- Straining at defecation
• Diarrhea:
- s/s of dehydration
- Frequent loose stools
- Abdominal cramping
Nursing Assessments:
• PE of the abdomen for BS and tenderness (auscultate before
palpation).
• S/S of fluid deficit
• Skin integrity around the anal area
• Collection of detailed history of the client’s diet, exercise, and
bowel habits.
NANDA Nursing Diagnosis (Constipation and
Diarrhea)
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Constipation
Diarrhea
Fluid Volume Deficit
Impaired skin integrity
Nursing Interventions (Constipation and Diarrhea)
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Closely monitor client fluid status (D)
Monitor for client s/s of dehydration (D)
Closely monitor elimination pattern ( C) and (D)
Observe and document the character of BM ( C) and (D)
Carefully check for blood or pus. If the client is experiencing
diarrhea, measure the volume of the stool. (D)
Administer laxatives or enemas as prescribed ( C)
Encourage adequate fluid intake ( C)
Monitor skin integrity ( D)
Suggest that client’s who are taking ATB to eat yogurt to
help re-establish an intestinal balance of beneficial
bacteria.
Complications
• Constipation:
- Fecal Impaction
- Development of hemorrhoids and/or rectal fissure
- Bradycardia, hypotension, and syncope associated
with the Valsalva Maneuver (bearing down)
stimulation of Vagus Nerve..
- Monitor constipation carefully and take measures
to treat and prevent constipation
- Removing fecal impaction. Break apart the impact
slowly. Monitor V/S and response. Preceded by
application of glycerin or Bisacodyl (Dulcolax supp.)
Complications
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Diarrhea:
- Dehydration. Monitor for s/s of fluid and electrolyte imbalance. Monitor for
metabolic acidosis cause by excessive loss of bicarbonate.
- Skin breakdown around the anal area. Carefully
follow skin protocol.
- Replace losses as prescribed.
Replacing Fluids and Electrolytes
• Drinking fluids is important during bouts of diarrhea to prevent dehydration, which
is the loss of vital fluids and electrolytes (sodium and potassium). Proper hydration
is especially important in children with diarrhea because they can die from
dehydration within a couple of days.
• Although water is extremely important in preventing dehydration, it does not
contain electrolytes.
• Good choices to help maintain electrolyte levels include broth or soups (which
contain sodium) and certain fruit juices, soft fruits, or vegetables (which contain
potassium).
• For children, often recommend a special rehydration solution that contains the
nutrients they need. You can buy this solution without a prescription.
• Examples of rehydration solutions include Pedialyte®, CeraLyte®, and Infalyte®.
Older Adults
• Older adults clients are more susceptible to developing
constipation as bowel tone decreases with age and more at
risk for developing fecal impaction.
• Adequate fluid and fiber intake and exercise are important.
Instruct proper diet.
Vegetables, fruits (especially dried fruits), and some cereals
(whole wheat, bran, or oatmeal) are excellent sources of fiber.
It is easy to remember that the harder a vegetable is (like
celery), the more fiber it has. To reap the benefits of fiber, it is
very important to drink an adequate amount of water to help
with the passage of stool in the intestines.
Hemorrhoids
• Hemorrhoids are dilated hemorrhoidal veins.
– Internal: occurring above the internal sphincter
– External: occurring outside the external sphincter
Are the most common reason for bleeding with defecation, can
lead to iron deficiency anemia
Precipitated factors: pregnancy, constipation, prolonged standing
and sitting, portal HTN (ex: cirrhosis)
Collaborative care: digital exam, anoscopy, sigmoidiscopy,
Rubber band ligation is the most common technique. The rubber
band around the hemorrhoid constricts the circulation, tissue
become necrotic, separates
and sloughs off.
Cryotherapy-rapid freezing of the hemorrhoid. Less often usedb/c of acute pain.
A warm sitz bath provides comfort and keeps are clean
Stool softner- docusate (Colace)
Ostomy
• An Ostomy is a surgical procedure that allows intestinal
content to pass from the bowel through an opening in
the skin on the abdomen.
• The intestinal contents will empty through the hole on
the surface of the abdomen instead of the abdomen
rather that being eliminated through the anus.
• Ileostomy, ascending, transverse and sigmoid
colostomy ( Lewis, 8th edition, table 43-27, page 1040)
• Pre and post operative care and patient teaching ;
ostomy self care.