Disorders of the Intestines (V 2.0) PDF

a\. Intestinal infections: \(1) Etiology: a. The infectious agent can enter the body by several routes. Most common entry is through the mouth by contaminated food or water. Some intestinal infections occur because of person-to-person contact. Fecal--oral transmission occurs thro...

a\. Intestinal infections: \(1) Etiology: a. The infectious agent can enter the body by several routes. Most common entry is through the mouth by contaminated food or water. Some intestinal infections occur because of person-to-person contact. Fecal--oral transmission occurs through poor hand hygiene after elimination. b. Bacterial flora grow naturally in the intestinal tract and help the immune system combat infection. However, long-term use of antibiotics can alter the normal bacterial flora in the intestines. This can lead to an overgrowth of other opportunistic bacteria such as C. difficile. c. Opportunistic bacteria such as clostridium, salmonella, campylobacter and shigella produce toxic substances and the mucosal cells respond by secreting water and electrolytes, causing an imbalance. The amount of fluid secreted exceeds the ability of the large intestine to reabsorb the fluid. d. One strain of E. coli often has a virulent course. Unlike other strains, E. coli is not part of the normal flora of the human intestine. It is transmitted in contaminated, undercooked meats such as hamburger, roast beef, ham, and turkey; in produce that has been rinsed with water contaminated by animal or human feces; or by a person who has been handling contaminated food. Hemorrhagic colitis (which results in bloody diarrhea and severe cramping accompanied by diffuse abdominal tenderness) develops between the second and fourth days. Antidiarrheals should not be given because these medications prevent the intestines from getting rid of the E. coli pathogen. \(c) C. difficile is a facility acquired infection because hospitalized \(2) Clinical Manifestation: \(a) Diarrhea is the most common clinical sign. \(b) If the intestinal mucosa is directly invaded, there may be blood and mucus in the stool. \(3) Assessment: a. Diarrhea, rectal urgency, tenesmus (ineffective or painful straining with defecation), nausea, abdominal cramping, fever and vomiting are all signs of an intestinal infection. \(b) Obtain history; has the patient been on antibiotics recently, has there been recent travel and what has been the patient\'s food intake. Noninfectious diarrhea may be caused by heavy metal poisoning or shellfish allergy. \(4) Diagnostic tests: The primary test is a stool culture. Stools are examined for blood, mucus, and WBCs. A blood chemistry test may be ordered to monitor any changes in fluid and electrolyte balance. \(5) Medical management: \(a) Generally, treatment is conservative letting the body take care of the \(b) Fluid and electrolyte replacement may be indicated. b. Antidiarrheals and antispasmodics may be contraindicated because they prolong the contact of the infection in the intestines. \(6) Nursing management: a. If oral intake is tolerated, offer apple juice, clear carbonated beverages, clear broth, plain gelatin, and water. b. Monitor weight loss if symptoms are severe, and maintain accurate I&O. \(c) Assess for fluid imbalance by: 1\) Measuring blood pressure. 2\) Assessing skin turgor. 3\) Checking the mucus membranes for hydration. 4\) Monitoring urine output. **(**Instructor recommendation: Ask the students what each of the measure will be if fluid imbalance is present.)**\ ** c. Encourage verbalization of concerns and assist with goal setting to manage the disease. \(d) Teach the importance of hand washing after bowel movements. \(e) Teach the proper methods of food preparation and storage to reduce the +-----------------------------------+-----------------------------------+ | Patient Problem | NURSING INTERVENTIONS | +-----------------------------------+-----------------------------------+ | Fluid volume, deficient, related | 1\) Offer clear liquids, as | | to excessive losses from diarrhea | tolerated. (Pedialyte, | | and vomiting | Gatorade) | | | | | | 2\) Administer medications as | | | needed, with antispasmodics and | | | antidiarrheal agents. | | | | | | 3\) Strict I&O. | +-----------------------------------+-----------------------------------+ | Nutrition, imbalanced: less than | 1\) Monitor episodes of | | body requirements related to | diarrhea. | | decreased intake and decreased | | | absorption | 2\) Monitor blood pressure, | | | mucous membranes, and urinary | | | output. | | | | | | 3\) Monitor weight loss if | | | symptoms are severe. | | | | | | 4\) Monitor total protein and | | | albumin lab values. | +-----------------------------------+-----------------------------------+ b\. Celiac Disease (Celiac Sprue) 1. Etiology: a. Celiac disease is a genetic disorder that most commonly affects the small intestine but can affect any part of the GI system. b. It is considered an autoimmune disease that disrupts the absorption of nutrients from foods in response to the ingestion of gluten (a protein primarily found in wheat, rye, and barley). c. When these proteins are ingested, the immune system begins damaging the inner lining of the small intestine and destroying the villi (finger-like protrusions lining the intestine). 2. Clinical Manifestations: Symptoms are individualized. a. Commonly, abdominal pain and diarrhea after ingesting foods containing gluten is experienced. b. Malabsorption occurs as damage to the lining of the small intestine prevents digestion from occurring resulting in weight loss. c. Vitamin deficiencies may be so severe that the brain, peripheral nervous system, bones, liver, and other vital organs are affected. Overview of celiac disease: [Celiac Disease \| Clinical Presentation - YouTube](https://www.youtube.com/watch?v=RDpcMDH3JhA) 3\. Assessment: a. Subjective Data -- abdominal pain and bloating, irritability and depression, joint pain, muscle cramps, neuropathic complaints such as tingling in the legs and feet, and general weakness and fatigue. b. Objective Data - chronic intermittent diarrhea, weight loss, osteoporosis, mouth sores, dental problems, unexplained iron deficiency anemia, and pale, foul-smelling stools that contain a large amount of fat. 4\. Diagnostic Tests: a. (Anti--tissue transglutaminase antibodies \[TGAs\] or antiendomysial antibodies \[EMAs\]) are performed while the patient still is ingesting gluten. b. Intestinal biopsy via an endoscopy is performed if blood tests are positive for the disease. 5\. Medical Management: There is no medical treatment for celiac disease other than following a gluten-free diet. a. Referral to a dietitian is most beneficial for a patient newly diagnosed with the disease. b. Vitamins and supplements may be ordered by the health care provider for severe deficiencies. c. Steroids also may be prescribed to treat extensive inflammation of the intestinal lining. 6\. Nursing Interventions: a. Teaching on gluten-free diet. Foods containing wheat, rye and barley are PROHIBITED! b. Refrain from wheat flour, grains, most cereals, pastas, and many processed foods. c. Replace gluten foods with potato, rice, soy, amaranth, quinoa, buckwheat, and bean flour to prevent flare ups. c\. Irritable Bowel Syndrome \(1) Etiology: \(2) Clinical Manifestation: Alterations of bowel function include a. Abdominal pain relieved after a bowel movement; more frequent bowel movements with pain onset. b. A sense of incomplete evacuation; flatulence; and constipation, diarrhea, or both. \(3) Assessment: a. Subjective data include complaints of abdominal distress,pain at onset of bowel movements, abdominal pain relieved by defecation, and feelings of incomplete emptying after defecation. b. Objective data include the presence of mucus in stools,visible abdominal distention, and frequent or unformed stools. \(4) Diagnostic tests: a. Diagnosis is by exclusion. Once other GI disorders such as colorectal cancer, ulcerative colitis, diverticulitis, infections such as salmonella, and Crohn\'s disease are ruled out then the IBS is a probable diagnosis. \(b) A complete history and physical exam are required. \(5) Medical management: Although stress does not cause IBS, it can make the symptoms worse. Stress management techniques, biofeedback, relaxation therapy, and hypnosis are some of the cognitive therapies used to manage IBS. Keeping a diary also may help with identifying lifestyle and diet issues that may worsen symptoms, thus allowing modifications of these issues. a. Increasing dietary fiber increases stool bulk, frequency of passage, and bloating. Fiber is more reliably provided with bulking agents (e.g. Metamucil) than with diet unless the patient is a strict vegetarian. Bulking agents seem most effective in treating constipation-predominant IBS, although it may alleviate mild diarrhea. b. If primary symptoms are abdominal distention and increased flatulence patient should eliminate common gas-producing foods (e.g., broccoli, cabbage) and substitute yogurt for milk products to determine if lactose intolerant. c. If certain foods exacerbate the condition, they should be eliminated. d. Medications: a. Anticholinergic drugs may be used to relieve abdominal cramps. b. Milk of magnesia may be prescribed if constipation does not respond to augmented fiber. c. Anti-anxiety drugs (Ativan, Valium, Librium) may help patients suffering from panic attacks associated with IBS. They should be given with food or meals and suggest to the patient that gum or hard candy can reduce the discomfort of dry mouth. d. Antidepressants may be used sparingly. e. Psychological non-pharmacologic treatment may include counseling and cognitive behavioral interventions such as hypnotherapy and muscle relaxation techniques to reduce stress. \(6) Nursing management: a. Most patients with IBS learn to cope with their symptoms enough to live in reasonable comfort. b. Teach the patient to keep a log of diet, an elimination pattern log, side effects of medications and life stressors that aggravate the disorder. d. Patient should be encouraged to verbalize concerns of anxiety. e. Diet management and ways to control anxiety are areas for patient teaching. +-----------------------------------+-----------------------------------+ | Patient Problem | Nursing Interventions | +-----------------------------------+-----------------------------------+ | Pain/Discomfort, related to diet | 1\) Emphasize daily food log and | | consumed and bowel evacuation | relation to pain. | +-----------------------------------+-----------------------------------+ | Knowledge deficient, related to | 1\) Patient teaching regarding | | the effect of fiber on spastic | the relationship of fiber to | | bowel | constipation and diarrhea. | | | | | | 2\) Patient teaching regarding | | | the use of bulking agents. | +-----------------------------------+-----------------------------------+ a\. Ulcerative Colitis: \(1) Etiology: a. Characterized by inflammation and ulceration of the colon and rectum. It can effect segments of the colon and usually starts in the rectum and moves toward the cecum. It affects the mucosa and sub-mucosa of the colon. There are alternating periods of exacerbation and remission. \(b) Capillaries bleed, causing diarrhea containing pus and blood. b. Pseudopolyps are common and may become cancerous. With the formation of scar tissue, the colon may lose elasticity and absorptive capability. \(2) Clinical Manifestation: a. Patients with severe disease may have 15 to 20 liquid stools a day, containing blood, mucus, and pus. b. With severe diarrhea, losses of sodium, potassium, bicarbonate, and calcium ions may occur. Abdominal cramps may occur before bowel movement. c. The major symptoms are bloody diarrhea and abdominal pain. d. This results in involuntary leakage of stool. In mild to moderate ulcerative colitis, diarrhea may consist of two to five stools per day with some blood present. e. Complications Include: (**Review Table 45.3**) Page 1422, Foundations and Adult Health Nursing. 1\) Toxic megacolon (dilation of the large bowel) in which the bowel can perforate. This occurs in less than 5% of patients. 2\) Chronic ulcerative colitis, lasting 10 to 15 years, can lead to carcinoma of the colon in 40 to 50% of the cases. \(3) Assessment: \(a) Subjective: patient will complain of rectal bleeding and abdominal cramps. Look for lethargy and frustration due to a loss of control and the unpredictability of bowel movements. \(b) Objective: data includes weight loss, abdominal distension, fever, tachycardia, leukocytosis and observation of frequency and characteristic of stools. \(4) Diagnostic tests: \(a) Double-contrast barium studies of the intestine. \(b) Sigmoidoscopy. \(c) Colonoscopy with possible biopsy. c. Checking stools for melena. d. Radiologic Exam of the abdomen. \(e) Labs to include serum electrolytes, albumin, and liver function. \(5) Medical management: a. Medications-There are four major categories of drugs used. 1. Drugs that affect the inflammatory response to include corticosteroids. a. Sulfasalazine (Azulfidine) is a common medication used for mild chronic ulcerative colitis. b. It affects the inflammatory response and provides some antibacterial activity. It is effective in maintaining clinical remission and in treating mild to moderately severe attacks. 2. Antibacterial drugs -- used to treat the infection. 3. Drugs that affect the immune system -- These drugs reduce the body\'s natural immune responses and may reduce the inflammation associated with ulcerative colitis a\. Remicade, Methotrexate are commonly used immunosuppressants. 4. Antidiarrheal preparations -- Treats diarrhea but not the cause. e. Loperamide may be used to treat cramping and diarrhea of chronic ulcerative colitis. Azathioprine (Imuran) is also beneficial a. Diet intervention - Inflammatory bowel disease has no universal food triggers, but patients may find that certain foods initiate diarrhea. 5. Goal is to provide adequate nutrition without making symptoms worse 6. A food diary helps to identify problem foods to avoid b. Stress reduction-Identify stressors and work with patient to find healthful coping mechanisms. c. Surgical Intervention: 7. If an acute episode does not respond to treatment, if complications occur, or if the risk of cancer becomes greater, surgical intervention is indicated. 8. 25 to 40% of cases require surgery. 9. Most surgeons prefer a conservative approach, removing only the diseased portion of the colon. (see box 45.3 & 45.4) Page 1424 -1425 (Foundations and Adult Health Nursing) 10. There are several choices for **[surgical procedures]** depending on the patient's condition and severity of the disease. i. The operations of choice may be a single-stage total proctocolectomy with construction of an internal reservoir and valve (Kock pouch). ii. Total [ **proctocolectomy**] with an ileoanal anastomosis (surgical joining of two areas to allow flow from one area to another) with or without an internal reservoir. iii. Temporary ileostomy. \(6) Nursing management: a. A thorough assessment of the patient's bowel elimination, support systems, coping abilities, nutritional status, pain, and understanding of the disease process and treatment is necessary. Assess for inadequate coping mechanisms as the onset is typically in the teen to early adult years. b. Provide emotional support. c. Explain all procedures and treatments to allay apprehension. Patient needs a complete understanding of the care plan so they can make informed choices. Prevention of future episodes is a goal. d. Until the diarrhea is controlled, the patient must be kept clean, dry and free of odor. e. Pre and post-operative care if applicable. f. Patient teaching to include explanation of all procedures and expected outcomes. Care of an ostomy pouch if applicable. g. Areas of concern are bowel and urinary elimination; fluid and electrolyte balance; tissue perfusion; comfort and pain; nutrition; gas exchange; infection; and, in the case of ostomy construction, assessment of the ileostomy and peristomal skin integrity. h. Prognosis: directly related to the number of years the client has had the disease. Incidence of carcinoma increases when the colon is extensively involved over time. +-----------------------------------+-----------------------------------+ | Patient Problem | Nursing Interventions | +-----------------------------------+-----------------------------------+ | Nutrition, imbalanced: less than | 1\) Provide small, frequent | | body requirements, related to | meals. | | bowel hypermotility and decreased | | | absorption | 2\) Eliminate food that | | | aggravates condition. | +-----------------------------------+-----------------------------------+ | Powerlessness, related to loss of | 1\) Assist weakened patient with | | control of body function | ADLs. | | | | | | 2\) Offer choices to patient | | | when possible, to facilitate | | | patient control. | +-----------------------------------+-----------------------------------+ b\. Crohn\'s Disease: \(1) Etiology: a. Characterized by inflammation of segments of the GI tract. b. Cause is not known but there seems to be an association with altered immune mechanisms. c. Can occur anywhere in the GI tract from the mouth to the anus but occurs most commonly in the terminal ileum and proximal colon. d. Inflammation involves all layers of the bowel wall. e. Ulcers form vertically and longitudinally in specific areas along the colon creating a cobblestone appearance. Areas of involvement are discontinuous, with segments of normal bowel occurring between diseased portions. f. Commonly occurs during adolescence and early adulthood with a second peak in the sixth decade. g. Malabsorption is a major problem when the small intestine is involved leading to nutritional problems and decreased absorption of vitamin B12 in the small intestine. \(2) Clinical Manifestation: a. The manifestations depend largely on the anatomic site of involvement, extent of the disease process, and presence of complications. b. The onset of Crohn's disease is usually insidious, with nonspecific complaints such as diarrhea, fatigue, abdominal pain, weight loss, and fever. \(c) As the disease progresses, there is weight loss, malnutrition, dehydration, electrolyte imbalances, anemia, increased peristalsis and pain. This is a chronic disease with unpredictable periods of recurrence and remission. \(3) Assessment: a. Subjective Data: weakness, loss of appetite, abdominal pain and cramps, intermittent low-grade fever and stress. Right-lower-quadrant abdominal pain is characteristic of the disease and may be accompanied by a tender mass of thickened intestines in the same area b. Diarrhea to include, three or four semisolid stools daily, containing mucus and pus, but usually no blood. \(c) Steatorrhea (excess fat in the feces) also may be present if the ulceration extends high in the small intestine. With small intestine involvement, weight loss occurs from malabsorption. \(d) Scar tissue from the inflammation narrows the lumen of the intestine and may cause strictures and obstruction, a frequent complication. Intestinal fistulas are a cardinal feature and may develop between segments of bowel. d. Cutaneous fistulas, common in the perianal area, and rectovaginal fistulas may occur. Fistulas communicating with the urinary tract may cause urinary tract infections. Poor absorption of bile salts by the ileum may lead to watery stools. e. Fever and unexplained anemia also may occur \(4) Diagnostic tests: a. The most definitive test to differentiate Crohn's disease from ulcerative colitis is colonoscopy with multiple biopsies of the colon and terminal ileum. b. Blood tests for anemia also may be ordered. c. Endoscopy may be ordered. \(5) Medical management: a. Treatment is individualized depending on the patient's age, the location, and severity of the disease, and any complications present. b. Once Crohn's is diagnosed, the patient is started on drug therapy to try to get the disease in remission. \(a) First line drugs: 1\) Anti-inflammatory agents (Sulfasalazine) are indicated for mild to moderate cases. \(b) Second line drugs: 11. Immunosuppressive agents 12. Infliximab (Remicade) is the only medication specifically indicated for the treatment of Crohn\'s disease. This drug works by neutralizing tumor necrosis factor, a protein that causes much of the intestinal inflammation. 13. Other immunosuppressive agents include azathioprine; cyclosporine (Neoral, Sandimmune); methotrexate; and IV immunoglobulin. Adalimumab (Humira), and certolizumab pegol (Cimzia) \(d) Foods that can cause increased diarrhea are eliminated. They are cabbage, broccoli, caffeine, beer, sugar substitutes, highly seasoned foods, concentrated fruit juices, carbonated beverages, and fatty foods. Elemental diets like Criticare have shown to induce remission in 90% of patients with Crohn\'s disease because they require minimal digestion and reduce stool volume. \(6) Surgical Treatment: a. About 75% of patients eventually require surgery. b. Surgery produces remission; however, recurrence rates are high. c. Surgery is reserved for emergency situations (excessive bleeding, obstruction, peritonitis) or when medical treatment has failed. a. Total parenteral nutrition may be ordered in cases of severe disease and marked weight loss. Tube feedings that allow rapid absorption in the upper GI tract are begun, and then oral intake of a low-residue, high-protein, high-calorie diet is introduced gradually. (Monitor of I&Os) b. Vitamin supplements are frequently necessary, and vitamin B12is given when there is a marked loss of ileum. c. If anemia is present, iron dextran (Dexferrum) is given by Z-track injection (because of irritation to the tissues) Oral intake of iron is will not be effective because of intestinal ulceration. d. Ensure that a bedside commode/bedpan is easily available at all times due to the urgency and frequency of stools. (Empty content immediately and deodorizing the room maintain an aesthetic environment. e. The anal region may become excoriated from frequent stools. Assess the anal area regularly and keep it clean, using medicated wipes and sitz baths as these interventions promote comfort and hygiene for the patient. f. Identifying resources for emotional support in the family and community and among health professionals promotes coping skills and mental hygiene. +-----------------------------------+-----------------------------------+ | Patient Problem | Nursing Interventions | +-----------------------------------+-----------------------------------+ | Powerlessness, related to | 1\) Explore factors with the | | exacerbations and remissions | patient that aggravate the | | | disease. | | | | | | 2\) Assist the patient in | | | listing factors that can be | | | controlled (diet, stressors, | | | medication compliance, | | | self-monitoring). | +-----------------------------------+-----------------------------------+ | Nutrition, imbalanced: less than | 1\) Teach the importance of | | body requirements related to | daily weight, following diet | | bowel hypermotility and decreased | regimen and assessing energy | | absorption | levels. | | | | | | 2\) Monitor total protein and | | | albumin lab values. | +-----------------------------------+-----------------------------------+ a\. Etiology/Pathophysiology: 1. Appendicitis is the inflammation of the vermiform appendix located at the tip 2. Appendicitis is most common in adolescents and young adults (persons \(3) The inflammation occurs when the opening of the appendix becomes obstructed. a. The obstruction may result from accumulated feces (fecalith), foreign bodies, and tumor of the cecum or appendix b. If the appendix becomes obstructed and inflammation occurs, pathogenic bacteria (E. coli) begin to multiply in the appendix and infection develops with the formation of pus. c. If distention and infection are severe enough, the appendix may rupture, releasing its contents into the abdomen. The infection may be contained within an appendiceal abscess or may spread to the abdominal cavity, causing generalized peritonitis. b\. Clinical Manifestations: 1. Rebound tenderness is elicited by light palpation of the abdomen. (Increased pain felt when using the fingertips to press on the abdomen on the opposite side of the suspected problem, then quickly releasing pressure). This is also referred to as Rovsing's sign. 2. The patient often lies on the back or side with knees flexed in an attempt to decrease muscular strain on the abdominal wall. c\. Assessment: \(1) Subjective Data: \(a) The most common complaint is of constant pain in the right lower quadrant of the abdomen around McBurney's point (exactly halfway between the umbilicus and the crest of the right ileum). \(b) Pain may be accompanied by nausea and anorexia. \(2) Objective Data: \(a) vomiting \(b) fever \(c) elevated white blood cell count \(d) rebound tenderness \(e) rigid abdomen \(f) decreased or absent bowel sounds d\. Diagnostic Tests: \(1) White blood cell (WBC) count with a differential. (above 10,000/mm 3 \(2) An abdominal CT scan is helpful for diagnosis \(3) Urinalysis to rule out a urinary tract infection. e\. Medical Management: surgical intervention is the choice for acute appendicitis. 1. Until a decision is made about the surgery, a patient is given antibiotics and restricted from eating or drinking. \(2) In order to meet the patient\'s fluid needs, IV fluids are administered. 2. Analgesics are generally withheld initially to avoid masking symptoms that may affect the diagnosis. \(4) If symptoms worsen, the surgeon performs an appendectomy (removal of appendix) before it ruptures. \(5) Potential complications that can occur include: (see Safety Alert Box) \(a) Infection. \(b) Intraabdominal abscess. d. Mechanical small bowel obstruction. f\. Nursing Interventions: 1. Assesses the patient\'s vital signs and pain level. 2. Explain diagnostic tests and possible surgical procedures to relieve 3. Maintain bed rest and NPO status, provide comfort measures for pain 4. The patient's vital signs are monitored and documented every hour 5. Administer prescribed opioids after the health careprovider has assessed the patient. Opioids can mask symptoms of acute appendicitis. (Ice may be used in the meantime but NO heat) g\. Patient Teaching: 1. Patients are instructed to avoid heavy lifting or unusual exertion for several months. 2. Patient teaching may involve explanation for intravenous fluids with gradual advancement of diet from clear liquids to regular, depending on the return of peristalsis. 3. If antibiotics are prescribed postoperatively, the patient needs to be informed of the name, purpose, and side effects of each medication. 4. If complications occur, the nurse needs to ensure the patient understands the reason for interventions that may include NG tube or drainage tubes. +-----------------------------------+-----------------------------------+ | Patient Problem | Nursing Interventions | +-----------------------------------+-----------------------------------+ | Fluid volume, deficient, related | 1\) Monitor patient for signs of | | to vomiting | dehydration and fluid and | | | electrolyte balance (poor skin | | | turgor, flushed and dry skin, | | | coated tongue, oliguria, | | | confusion, abnormal sodium, | | | potassium, chloride). | +-----------------------------------+-----------------------------------+ | Pain, related to inflammation | 1\) Provide support to patient | | | and family through listening | | | and explanation of all tests | | | and procedures. | | | | | | 2\) Explain need to withhold | | | narcotics to avoid masking | | | condition. | | | | | | 3\) Monitor increase in amount | | | of pain experienced, rebound | | | tenderness and abdominal | | | rigidity. | | | | | | 4\) Frequent vital signs. | +-----------------------------------+-----------------------------------+ a\. Etiology/Pathophysiology: \(1) Diverticulosis and diverticulitis are two clinical forms of the diverticular disease. 2. ) Diverticulosis is the presence of pouch-like herniations through the muscular layer of the colon, particularly the sigmoid colon. \(3) Diverticulitis is the inflammation or infection of one or more diverticula. \(4) Diverticulosis affects increasing numbers of people older than 40 years of age and may be the result of the modern, highly refined, low-residue diet. a. Penetration of fecal matter through the thin-walled diverticula causes b. With repeated inflammation, the lumen of the colon narrows and may c. When one or more diverticula become inflamed, diverticulitis results, b\. Clinical Manifestations: \(1) Patients with diverticulitis will complain of pain mild to severe in the left lower quadrant of the abdomen, followed by fever and elevated white blood cell count and sedimentation rate. \(2) Septicemia and septic shock can result if the condition goes untreated. \(3) The patient will experience abdominal distention, nausea and vomiting if intestinal obstruction occurs. c\. Assessment: \(1) Subjective Data: \(a) An awareness that the patient with diverticulosis may not display any problematic symptoms. \(b) Complaints of constipation and diarrhea accompanied by pain in the lower-left quadrant are common to some. \(c) Other common symptoms include: 1\) increased flatus 2\) chronic constipation alternating with diarrhea 3\) anorexia 4\) nausea d\. Diagnostic Tests: \(1) CT scan with oral contrast is the test of choice for diverticulitis. \(2) A CBC, urinalysis, and fecal occult blood test should be performed. 3. A barium enema is used to determine narrowing or obstruction of the colonic lumen. 4. Colonoscopy may be beneficial in diagnosing certain cases and is especially helpful in ruling out carcinoma. 5. A patient with acute diverticulitis should not have a barium enema or colonoscopy because of the possibility of perforation and peritonitis. e\. Medical Management: \(1) Treatment depends on the cause. \(2) If muscle atrophy is responsible: a. Low-residue diet, stool softeners, and bed rest are traditional interventions. \(3) Increased intracolonic pressure and muscle thickening are causes: \(a) High-fiber diet of bran, fruits, and vegetables is recommended. \(4) Microperforation resulting in localized abscess is treated with a combination of antimicrobials effective against gram-negative, gram-postive, and anaerobic organisms. \(5) Analgesics are given per patient-controlled analgesia (PCA) for pain. 6. Patients with acute attacks that do not respond to antibiotics and bed rest may require hospitalization with NG drainage, parenteral fluids, and intravenous antibiotics. f\. Surgical Management: 1. Surgery is advised if long-term problems do not respond to medical 2. Surgery is mandatory if obstruction, perforation, abscesses or hemorrhage \(3) Temporary or permanent colostomy. \(4) Bowel resection in cases of perforation, abscess, peritonitis, or fistula. \(a) One stage procedure: resection of the affected bowel with anastomosis and no diverting colostomy. \(b) Two stage procedure: resection of the diseased bowel with diverting colostomy. \(5) The bowel diversion can be accomplished by Hartmann\'s procedure or double-barrel colostomy. \(a) Hartmann\'s procedure: the descending colon is resected, the proximal end is brought to the abdominal wall surface, and the distal bowel is sealed off for later anastomosis. \(b) Double-barrel colostomy: the bowel is brought up through the abdominal surface, or loop colostomy. NOTE: Removal of the affected bowel and reanastomosis are performed during the initial procedure. g\. Nursing Interventions and Patient Teaching: should include patient teaching in reference to the disease process and surgery, if planned. \(1) The goals of the teaching plan should include both patient and family/significant other. For patients that had colostomies performed, the nurse must ensure that patient and family/significant other understands ostomy care. \(2) The goal for the colostomy patient is patient independence. \(3) The nurse informs the patient to temporarily avoid foods that are high in fiber, which could contribute to inflammation of diverticula. \(4) Encourage the patient to drink 8 to 10 large glasses of water per day to replace fluid lost during periods of diarrhea. \(5) Avoid beverages containing caffeine. Instruct patient, if milk causes cramping, to use lactose-free products. When diarrhea subsides, gradually reintroduce foods that are higher residue. If the diarrhea intensifies, withhold all oral nourishment and notify the physician. \(6) Encourage the patient to assume a position of comfort. \(7) Provide activities that may distract the patient from discomfort. Administer analgesics, antispasmodics, and antidiarrheals as ordered and assess effectiveness. +-----------------------------------+-----------------------------------+ | Patient Problem | Nursing Interventions | +-----------------------------------+-----------------------------------+ | Knowledge, deficient, related to | 1\) Instruct patient and | | disease process and treatment | significant others in disease | | | process and signs/symptoms of | | | diverticular attack. | +-----------------------------------+-----------------------------------+ | Nutrition, imbalanced: less than | 1\) Instruct in dietary roughage | | body requirements related to | (for prevention) or bland, | | decreased oral intake | low-residue diet (for | | | inflammatory phase). | | | | | | 2\) Assess daily weights, | | | calorie counts, I&O. | | | | | | 3\) Monitor serum protein and | | | albumin. | +-----------------------------------+-----------------------------------+ 10\. Peritonitis. a\. Etiology/Pathophysiology: \(1) Peritonitis is inflammation of the abdominal peritoneum. 2. This condition occurs after fecal matter seeps from the rupture site, causing bacterial contamination of the peritoneal cavity. b\. Clinical Manifestations: \(1) This extremely serious condition is characterized by severe abdominal pain. The patient assumes the prone position with the knees flexed to relax the abdominal muscles; any movement is painful. \(2) The abdomen is usually tympanic and extremely tender to touch. c\. Assessment: \(1) Subjective Data: \(a) Severe abdominal pain \(b) any movement is painful \(c) Nausea and vomiting \(d) As peristalsis ceases, constipation occurs with no passage of flatus \(e) Chills \(f) Weakness \(g) Abdominal tenderness (local and diffuse, often rebound) \(2) Objective Data: \(a) weak and rapid pulse \(b) fever \(c) Lowered blood pressure \(d) Leukocytosis \(e) Marked dehydration \(f) The patient can collapse and die d\. Diagnostic Tests: 1. A flat plate of the abdomen (abdominal x-ray) is ordered to ascertain if free air 2. CBC with differential is ordered to determine the degree of leukocytosis 3. A blood chemistry profile to determine renal perfusion and electrolyte balance e\. Medical Management: 1. Aggressive therapy includes correction of the contamination or removal of the chemical irritant by surgery. \(2) Parenteral antibiotics. \(3) Nasogastric intubation is ordered to prevent GI distention. \(4) Intravenous fluids and electrolytes will prevent or correct imbalances. \(5) May be placed on total parenteral nutrition because of increased nutritional requirements. \(6) Early treatment to prevent severe shock from the loss of fluid into the peritoneal space is essential. e\. Nursing Interventions and Patient Teaching: \(1) Place patient on bed rest in semi-Fowler's position to help localize purulent exudates in lower abdomen or pelvis. \(2) Give oral hygiene to prevent drying of mucous membranes and cracking of lips from dehydration. \(3) Monitor fluid and electrolyte replacement. \(4) Encourage deep breathing exercises; patient tends to have shallow respirations as a result of abdominal pain or distention. \(5) Use measures to reduce anxiety. \(6) Use meticulous surgical asepsis for wound care. \(7) Teach the patient surgical asepsis if discharged with a draining wound. \(8) Encourage a nutritious diet. \(9) Instruct the patient not to lift more than 10 pounds until instructed by the physician to do so. \(10) Stress the importance of keeping physicians follow up appointments. +-----------------------------------+-----------------------------------+ | PATIENT PROBLEM | NURSING INTERVENTIONS | +-----------------------------------+-----------------------------------+ | Knowledge, deficient, related to | 1\) Instruct the patient and | | disease process | significant others in disease | | | process and signs/symptoms of | | | acute peritonitis. | +-----------------------------------+-----------------------------------+ | Alteration in comfort, related to | 1\) Assess the patient\'s pain | | surgery/disease process | level and medicate as ordered. | | | | | | 2\) Frequent vital signs. | +-----------------------------------+-----------------------------------+ A. Etiology: \(1) Most hernias result from congenital or acquired weakness of the abdominal wall or from a postoperative defect, coupled with increased intra-abdominal pressure from coughing or straining. \(2) Factors such as age, wound infection, malnutrition, obesity, increased intra- abdominal pressure, and abdominal distension affect the development of hernias after abdominal surgeries. \(3) More hernias occur with longitudinal incisions than with transverse incisions. **B**. Types of Hernias: there are four types of **[external hernias.]** 1. Ventral, or incisional, hernia: Due to weakness of the abdominal wall at the site of a previous incision. a. Most common in patients who a have had multiple surgeries in the same area. These patients have had inadequate wound healing due to poor nutrition or infection. \(b) Patients are typically overweight. \(2) Femoral Hernia: a. Caused by a weakness in the lower abdominal wall, resulting in a bulging of tissue in the patient's groin.. b. The hernia is strangulated when it occludes blood supply and intestinal flow. To prevent anaerobic infection in the area, immediate surgical intervention is performed when a hernia strangulates. \(3) Umbilical Hernia: \(a) Occurs when the rectus muscle is weak or the umbilical opening fails to close after birth. \(b) Most common in children. \(4) An inguinal hernia \(a) Found most often in obese patients who have had: 1. is caused by a weakness in the lower abdominal wall opening, through which the spermatic cord emerges in men and the round ligament of the uterus emerges in women. c. A hernia may be reducible (able to be returned to its original position by manipulation) or irreducible (or incarcerated; unable to be returned to its body cavity). When the hernia is irreducible, it may obstruct intestinal flow d\. Assessment: 1. Soft Nodule (omentum; the layer of tissue that surrounds the abdominal organs) or smooth and fluctuant (bowel). **Never** attempt to push a hernia back into place, because this can lead to complications such as **rupture of the strangulated contents.** 2. Visible protruding mass or bulge around the umbilicus, in the inguinal area, or near an incision, this is the most common objective sign. \(3) If complications such as incarceration or strangulation follow, the patient may have bowel obstruction, vomiting, and abdominal distention. f\. Diagnosis: \(1) Palpation of the weakened wall. \(2) Radiographs of the suspected area. g\. Medical Management: \(1) Hernias can be left unrepaired unless complications occur. \(2) Patient should be taught to seek medical attention promptly if abdominal pain, distension, change of bowel habits, temperature elevation. The hernia can be manually reduced using a truss or firm pad placed over the hernia site and held in place with a belt. \(3) Elective surgery can be performed by approximating the adjacent muscles or h\. Hiatal Hernia: Typically occurs over the age of 50. \(1) Also called an esophageal or diaphragmatic hernia. diaphragmatic esophageal hiatus. a. The majority of hiatal hernias is asymptomatic and is discovered incidentally. 2. The major difficulty in symptomatic patients is gastroesophageal reflux, manifested as pyrosis (heartburn) after overeating. 3. Is an anatomical condition not a disease. b. On rare occasion, a life-threatening complication, such as gastric volvulus or strangulation, may present acutely. c. Muscle weakening and loss of elasticity as people age is thought to predispose to hiatal hernia. Loss of muscle tone around the diaphragmatic opening also may make it more patulous. \(e) Diaphragmatic hernias may be congenital or acquired. \(f) Predisposing factors: 1\) Obesity. 2\) Trauma. 3\) General weakness of the supporting structures. 3. Medical Management: a. Posterior gastropexy - the stomach is returned to the abdomen and sutured in place. b. Laparoscopically performed **Nissen fundoplication**, in which the fundus of the stomach is wrapped around the lower part of the esophagus and sutured in place. ----------- ------------------------------------------------------------------ **NOTE:** Conduct a check on learning and summarize the learning activity. ----------- ------------------------------------------------------------------ **CHECK ON LEARNING:** **[QUESTION:]** What is a reducible hernia? **[ANSWER:]** The protruding structure can be replaced in the abdominal cavity a\. Nursing Considerations (External Hernias): \(1) Observe and document the location and size of the hernia. \(2) Limit the patient\'s activity to decrease further strain on the abdomen. \(3) If surgery is required the nurse will manage NG suctioning, intravenous antibiotics, fluid and electrolyte replacement, and parenteral analgesics until peristalsis returns. \(4) If scrotal edema is present, it may be decreased by elevating the scrotum on a rolled pad, applying an ice pack, and providing a supportive device (jockstrap or briefs). \(5) Encourage deep breathing but discourage coughing. \(6) Teach the patient to splint the area with a pillow or pad. \(7) Follow-up teaching after surgery includes teaching the patient to limit activities and avoid lifting heavy objects to decrease further strain on the abdomen or straining with bowel movements for 5 to 6 weeks. \(8) Monitor the site for erythema, edema, draining, or pain. b\. Nursing considerations (Hiatal Hernia): \(1) Nursing interventions: \(a) Appropriate diet to maintain an ideal body mass index. \(b) Post gastric or thoracic surgery care. \(2) Patient Education: \(a) Potential for complications of each type of hernia. \(b) Complications of the hernia itself. \(c) Complications from reflux disease. \(d) Instruct patients to seek medical attention if new symptoms develop. a\. Etiology: May be Mechanical or Non-Mechanical \(1) Occurs when intestinal contents are unable to pass through the GI tract. a. Mechanical -- May be caused by an occlusion of the lumen of the intestinal tract. Most obstructions will occur in the ileum, which is the narrowest segment of the small intestine. b. Other mechanical obstructions include incarcerated hernias, impacted feces, diverticular disease, tumors of the bowel and intussusceptions. Volvulus is another cause which is a twisting of bowel onto itself or of the strictures of inflammatory bowel disease. (Residue, fruit pulp and coconut can obstruct small bowel). c. Nonmechanical -- May result from neuromuscular or vascular disorders. d. Paralytic (adynamic ileus) -- lack of intestinal peristalsis and bowel sounds. This is the most common form of non-mechanical obstruction. e. Inflammatory responses such as acute pancreatitis, appendicitis, electrolyte abnormalities (hypokalemia) and thoracic or lumbar spinal trauma. f. Vascular obstructions are rare but due to an interference with the blood supply to a portion of the intestines. The most common are emboli and atherosclerosis of mesenteric arteries. b\. Clinical manifestations: \(1) Auscultation will reveal loud, frequent, high-pitched sounds during partial or early phases of mechanical obstruction. \(2) Bowel sounds will be weak or absent with smooth muscle atony. c\. Assessment: \(1) Subjective Data: a. Obtain a history of bowel patterns and abdominal surgeries. b. Nausea c. Inability to pass gas d. Early intestinal obstruction will cause an increase in peristaltic activity proximal to the obstruction. This will manifest itself as spasms or cramping abdominal pain. \(e) As the obstruction progresses, the intestines become fatigued and there is decreased or absent bowel sounds. \(2) Objective Data: \(a) Assess the patient\'s abdomen for distension, hernias, scars or visible peristaltic waves. \(b) Vomiting. \(c) Signs of dehydration caused by fluid shift. \(d) Abdominal tenderness. \(e) Muscle guarding. \(f) Decreased blood pressure. \(g) High pitched bowel sounds then progress to absent. d\. Diagnostic Tests: 1. Radiographic examination. (Free air under the diaphragm indicates perforation) \(2) Sigmoidoscopy or colonoscopy \(3) CT scan 4. Electrolyte serum test to evaluate electrolyte imbalance. Elevated BUN, decreased serum sodium, chloride, potassium, and magnesium are common. 5. Hematocrit and hemoglobin e\. Medical Management: 1. Decompression of the intestine by removal of gas and fluid, correction and maintenance of fluid and electrolyte balance, and relief or removal of the obstruction. 2. An NG or nasojejunal tube is inserted and connected to wall suction to decompress the intestine. \(3) Fluid and electrolyte replacement through intravenous infusions. 2. Non-opioid analgesics are given in place of opioids to treat the pain. Non- a\. For patients not requiring surgery the nursing interventions include: \(1) Careful monitoring of fluids and electrolytes. \(a) Nausea. \(b) Vomiting. \(2) Observation of the function of tubes used to decompress and relieve distension. \(3) Administer analgesics as needed. b\. For patients undergoing surgery: \(1) Explaining the procedure to the patient. \(2) Providing emotional support due to the stress of the surgery and the stressors associated with the obstruction. \(3) Postop Nursing interventions include placing the patient in Fowler\'s position for greater diaphragm expansion. Also encourage deep breathing and coughing. \(4) Do not discontinue NG suctioning until bowel activity returns. \(5) Assess bowel sounds and abdominal girth. \(6) Administer analgesics. \(7) Follow-up teaching includes dietary management, prevention of constipation and recognition of early signs of recurrence. 8. Teaching associated with ostomy care will be required for those patients with 1. CANCER OF THE COLON AND RECTUM (COLORECTAL CANCER) - Etiology and PathophysiologyMalignant neoplasms that invade the epithelium and surrounding tissue of the colon and rectum are the third most prevalent internal cancers in the United States and the second leading cause of cancer deaths. Most growths are seen in the sigmoid and rectal areasof the colon. - Cancer occurs with the same frequency in men and women; 9 of 10 colorectal cancer cases occur in people 50 years of age and older. The cause of colorectal cancer remains unknown, but certain conditions appear to make patients more susceptible to malignant changes. These conditions are termed predisposing or risk factors. Fortunately, about 85% of colorectal cancers arise from adenomatous polyps, which can be detected and removed from the rectum and sigmoid colon by sigmoidoscopy or colonoscopy. - Some diseases, including ulcerative colitis and diverticulosis, increase the risk of colorectal cancer over time. Recent research has isolated a gene that causes colon cancer in certain families. Hereditary diseases (e.g., familial adenomatous polyposis) account for about 5% to 10% of colorectal cancer cases. Hereditary nonpolyposis colorectal cancer syndrome, also called Lynch syndrome, is the most common inherited form of hereditary colorectal cancer. History-taking and regular checkups are important preventive measures. - Other factors implicated in colorectal cancer include lack of bulk in the diet, high fat intake, and high bacterial counts in the colon. It is theorized that carcinogens are formed from degraded bile salts, and the stool that remains in the large bowel for a longer period as a result of too little fiber to stimulate its passage may overexpose the bowel to these carcinogens. Another theory is that the increased transit time for low-fiber foods to pass through the intestine is related to malignancy. These factors support certain dietary changes: decreased animal fat, reduced red meat, and increased high dietary fiber found in fruits, vegetables, and bran may have a protective effect and act as a primary preventive measure. Smoking, excessive intake of alcohol, obesity, and diabetes also have been identified as risk factors. 2. Clinical Manifestations Signs and symptoms of cancer of the colon vary withthe location of the growth. During the early stages, most patients are asymptomatic. Clinical 3. Assessment Subjective data include changes in bowel habits alternating between constipation and diarrhea, excessive flatus, and cramps. Constipation is more likely with descending colon cancer, whereas ascending colon cancer may produce no change in bowel habits. Another complaint may be rectal bleeding (the most common sign of colorectal cancer), with the color varying from dark to bright red, depending on the location of the neoplasm. Later stages of colon cancer may involve subjective symptoms of abdominal pain, nausea, and cachexia (weakness and emaciation associated with general ill health and malnutrition). Collection of objective data includes observing for vomiting, weight loss, abdominal distention or ascites, and test results that are compatible with the diagnosis. The most common clinical manifestations are chronic blood loss and anemia. 4. Diagnostic Tests: Early diagnosis of the tumor, including identification of the cell type involved, is the most important factor in treating the disease. Fecal occult blood tests are an early screening test used to assist in colon cancer detection. Because half of all cases are found in areas of the colon that are inaccessible by sigmoidoscopy, colonoscopy is considered the gold standard for colorectal cancer screening and the detection and removal of precancerous polyps. Other procedures include endorectal ultrasonography and CT scan of the abdomen and pelvis to localize the lesion or determine its size. A baseline colonoscopy before age 50 should be performed on those who have a family history of colon cancer. Individuals with known gene mutations need to be monitored by colonoscopy every year. 5. Routine physical examinations should include a digitalrectal examination, because rectal polyps and cancer can be reached with a finger, but this method should not be used for fecal occult blood testing. The American Cancer Society has established guidelines for colorectal cancer screening (see the Health Promotion box). In addition to these recommendations other laboratory and diagnostic studies include a UGI series, radiologic abdominal series, and barium enema. Hemoglobin, hematocrit, and electrolyte levels are examined and, if cancer and metastasis are suspected, a blood test is done to detect antibodies to carcinoembryonic antigen (CEA) (an oncofetal glycoprotein, found in colonic adenocarcinoma and other cancers and in nonmalignant conditions; oncofetal means occurring in both cancerous tissue and fetal tissue). Because the CEA level can be elevated in benign and malignant diseases, it is not considered a specific test for colorectal cancer. Its use is limited to determining the prognosis and monitoring the patient's response to antineoplastic therapy. Newer diagnostic studies used in colorectal cancer screenings and diagnostics include stool DNA testing. Cologuard DNA testing method was approved by the US Food and Drug Administration (FDA) in 2014. It detects minute amounts of blood in the stool. It also detects nine DNA biomarkers and three genes that have been found in colorectal cancers. 6. Screening for Colorectal Cancer Health PromotionCurrent recommendations from the American Cancer Society for colorectal cancer screening are as follows: Starting at the age of 50 years, fecal testing for occult blood every year Flexible sigmoidoscopy every 5 years (colonoscopy if test results are positive) Colonoscopy every 10 years Double-contrast barium enema every 5 years CT colonography (virtual colonoscopy) every 5 years Tests that are done mainly to find cancer: Fecal occult blood test (FOBT) every year Fecal immunochemical test (FIT) every year Stool DNA (sDNA) test Screening for high-risk patients beginning before age 50, usually by colonoscopy 7. Medical Management Medical treatment includes radiation, chemotherapy, and surgery. Radiation therapy often is used before surgery to decrease the chance of cancer cell implantation at the time of resection. Radiation can reduce the size of the tumor and decrease the rate of lymphatic involvement. Radiation before surgery has few side effects but some potential complications. Postoperatively, those patients at high risk for recurrence or people whose disease has progressed may receive radiation administered over 4 to 6 weeks. 8. Chemotherapy is given: \(1) to patients with systemic disease that is incurable by surgery or radiation alone; \(2) to patients in whom metastasis is suspected (e.g., when a patient has positive lymph node involvement at the time of surgery); or \(3) for palliative therapy to reduce tumor size or relieve symptoms of the disease, such as obstruction or pain. Health care provider opinion and individual patient response vary regarding use of chemotherapy for colorectal cancer. Surgical interventions depend on the tumor's location, presence of obstruction or perforation of the bowel, possible metastasis, the patient's health status, and the surgeon's preferences. When obstruction has not occurred, a portion of the bowel on either side of the tumor is removed and an end-to-end anastomosis (EEA) is done between the divided ends. 9. When obstruction of the bowel occurs, the commonly used procedures are as follows: One-stage resection with anastomosis Two-stage resection with \(1) the ends of the bowel brought to the surface and creation of a temporary colostomy and mucus fistula or Hartmann's pouch \(2) a double-barrel colostomy; or \(3) a temporary loop colostomy for closure later Surgical procedures for colorectal cancer include the following: Right hemicolectomy: Resection of ascending colon and hepatic flexure); ileum anastomosed to transverse colon Left hemicolectomy: Resection of splenic flexure, descending colon, and sigmoid colon; transverse colon anastomosed to rectum Anterior rectosigmoid resection: Resection of part of descending colon, the sigmoid colon, and upper rectum descending colon anastomosed to remaining rectum 10. In carcinoma of the rectum, the surgeon makes every effort to preserve the sphincter, often with an EEA. The use of EEA staplers allows lower and more secure anastomosis. The stapler is passed through the anus, where the colon is stapled to the rectum. - This technique makes it possible to resect lesions as low as 5 cm from the anus. If the surgeon is unable to perform an anastomosis, an abdominoperineal resection may be done. In the abdominoperineal resection, an abdominal incision is made and the proximal sigmoid is brought through the abdominal wall in a permanent colostomy. The distal sigmoid, rectum, and anus are removed through a perineal incision. The perineal wound may be closed around a drain or left open with packing to allow healing by granulation. Possible complications are delayed wound healing, hemorrhage, persistent perineal sinus tracts, infections, and urinary tract and sexual dysfunction. - Nutritional status is important because of the threat of infection and a compromised postoperative healing process as a result of constipation, diarrhea, nausea, vomiting, and possible obstruction. 11. Nursing Interventions and Patient Teaching Nursing interventions include assessment of bowel and urinary elimination, fluid and electrolyte balance, tissue perfusion, nutrition, pain, gas exchange, infection, and peristomal skin integrity, as discussed previously. - Preoperative care. The patient has some type of bowel preparation, which usually includes 2 or 3 days of liquid diets; a combination of laxatives, or enemas; and oral antibiotics to sterilize the bowel. The antibiotic of choice may be neomycin, kanamycin, or erythromycin; each suppresses anaerobic and aerobic organisms in the colon. - Before surgery, provide instruction in turning, coughing, and deep breathing; use of an incentive spirometer; wound splinting; and leg exercises. Inform the patient that he or she will have IV lines, a Foley catheter, possibly an NG tube, a Davol drain, and abdominal dressings after surgery If a stoma is planned, the enterostomal therapist should be notified so that the stoma site can be marked before surgery. The stoma should be placed at the best site for the patient. - Postoperative care. Assess the patient for stable vital signs and return of bowel sounds. Check the dressings for drainage or bleeding and change them as needed as per the health care provider's order. Monitor the NG tube, any wound drains, and the Foley catheter for rate of flow and color of output. Keep accurate I&O records to maintain the fluid and electrolyte balance. Other postoperative care includes coughing, deep breathing, early ambulation, adequate nutrition, pain control, and meticulous wound and stoma care. - Paralytic ileus, a common complication of abdominal surgery, produces the classic signs of increased abdominal girth, distention, nausea, and vomiting. Interventions include decompression of the bowel with an NG tube connected to wall suction, NPO status, and increased patient activity. - Long-term complications of abdominal resection with permanent colostomy are urinary retention or incontinence, pelvic abscess, failure of perineal wound healing, wound infection, and sexual dysfunction. In addition to monitoring the stoma for color, size, location, and the condition of the peristomal skin, watch for possible complications, including necrosis and abscess. Necrosis results from compromised blood flow to the stoma; the stoma appears pale and dusky to black. Abscess caused by stoma placement too close to the wound, retention sutures, and drains must be assessed promptly. Report all complications promptly to the surgeon and document them in the medical record. Patient problems and interventions for the patient with cancer of the colon include but are not limited to the following: - The patient with a permanent end colostomy can be taught two forms of colostomy management: \(1) emptying and cleansing the pouch as needed and \(2) managing colostomy irrigation. In planning patient teaching, consider past bowel habits; location of the colostomy; and the patient's age, general health, and personal preference. Nerves that control the bladder may be damaged when a large amount of tissue is removed in an abdominoperineal resection or if radiation therapy has occurred. When the Foley catheter is removed after surgery, the patient may be unable to void or empty the bladder completely. If the problem does not resolve, the patient may need a Foley catheter and a urology consultation. When a large amount of tissue is removed, as in an abdominoperineal resection, the cavity left is a sanctuary for bacteria, increasing the risk of infection. Monitor the drain site for increased pain, erythema, and purulent drainage, and monitor for elevated body temperature. The perineal wound may be closed using various techniques. The wound may be closed with a drain to suction. The semi closed wound usually has either a Davol or Penrose drain left in place, with the drain shortened over time by the health care provider or nurse. The open wound (in which packing is used and later removed) may need irrigation and sitz baths to facilitate healing. Any changes in exudate color and odor and temperature elevation are reported to the surgeon. Sexual dysfunction for men and women is related to removal of the rectum. Contributing factors may be partial to complete disruption of the nerve supply to the genital organs, psychological factors, or decreased activity associated with age. When the nurse and the patient have a comfortable relationship, it is easier to introduce the topic of sex. Exploring the patient's and the partner's fears and providing information on penile prosthesis surgery and simple suggestions to both partners help decrease anxiety concerning inter-course. Counseling may be necessary if the patient's and the partner's perceptions of body image have been altered. Support groups are available to the cancer patient in most communities. Above all, the nurse's silent communication of touch and eye contact can give the patient a message that he or she is accepted and valued. PrognosisThe 5-year survival rate for stage I colon cancer is approximately 92%. For stage IIA of the disease, the 5-year relative survival rate is about 87%; for stage IIB cancer, the survival rate is about 63%. Stage III colon cancers range from 89% for stage IIIA to 53% for stage IIIC. Metastatic stage IV colon cancer has a survival rate of 11% (ACS, 2016b). For more information on the staging of colorectal cancer visit www.cancer.org 9. a\. Etiology/Pathophysiology: Repeated increased pressure and obstructed blood flow causes permanent dilation to occur. Etiological factors include straining at stool with increased intraabdominal and hemorrhoidal venous pressures. b\. Factors contributing to hemorrhoid formation: \(1) Constipation. \(2) Diarrhea. \(3) Pregnancy. \(4) Congestive heart failure. \(5) Portal hypertension. \(6) Prolonged sitting and standing. c\. Clinical Manifestations: Most common with enlarged hemorrhoids are a prolapse and bleeding. (Protrusion outside the anal sphincter). Bright red bleeding and prolapse may typically occur during defecation. d\. Assessment: \(1) Subjective data - Noting patient\'s complaints of the following: \(a) Constipation. \(b) Pruritus. \(c) Severe pain on defecation. \(d) Bleeding from the rectum, not mixed with feces. \(2) Objective data - Observing external or palpating internal hemorrhoids for: \(a) Enlargement. \(b) Prolapse. \(c) Bleeding. \(3) Medical Management: High-fiber diet and increase fluid intake as a prevention in constipation to reduce straining. \(a) Conservative interventions: 1. Use of bulk stool softeners - such as Metamucil, bran, and natural food fibers - to relieve straining. 2. Topical creams and hydrocortisone relieve pruritus and inflammation. 3. Analgesic ointments, such as Dibucaine, relieve pain. 4. Sitz baths to relieve pain and edema to promote healing. \(b) Procedural interventions: 1. Rubber-band ligation - the application of tight bands around the hemorrhoid 2\) Sclerotherapy - inserting a sclerosing agent directly into the hemorrhoid. 3\) Cryotherapy - destroying the tissues by freezing. 4\) Infrared photocoagulation - destroying tissues by creating a small burn. \(c) Surgical interventions: Indicated for patients with prolapse, excessive pain or bleeding or large hemorrhoids. 1\) Hemorrhoidectomy - surgical removal of the hemorrhoids. NOTE: Hemorrhoidectomy is usually performed if other interventions fail to relieve distressing signs and symptoms. Complications include hemorrhage, local infection, pain, urinary retention and abscess. 1\. Anal fissures and fistulas. a. Etiology - An anal fissure is a linear ulceration or laceration of the skin of the anus. Usually, it is the result of trauma caused by hard stool that overstretches the anal lining. The fissure is aggravated by defecation, which initiates spasm of the anal sphincter; pain; and, at times, slight bleeding. b. An anal fistula is an abnormal opening on the cutaneous surface near the anus. Fistulas can form a local crypt abscess and is common in Crohn\'s disease. May or may not connect with the rectum. Results from rupture or drainage of an anal abscess. c. If the lesion does not heal spontaneously, the tract is excised surgically. b\. Clinical manifestations: \(1) Pain. \(2) Spasm. \(3) Slight bleeding. c\. Medical management: \(2) Post-operative care is similar to that for a patient who has had a hemorrhoidectomy. 1\. 1. Nursing care for hemorrhoids, fissures and/or fistulas. a\. Nursing interventions / Patient teaching: For patients with hemorrhoids, fissures or fistulas: (Review patient problem list along with nursing interventions on page 1440) \(1) Obtain a thorough patient history. \(2) Assess knowledge level by: \(a) Asking about their condition. \(b) What they have been told about treatment. \(c) What treatments have been done before surgery and why. \(5) Avoid prolonged use of laxatives. b\. Nursing interventions - For patients with a prolapsed hemorrhoid: \(1) Assess for: \(a) Edema. \(b) Thrombosis. \(c) Ischemia. NOTE: Ischemic tissue will be dark red to black (necrotic). c\. Nursing interventions - For the surgical patient: \(1) Frequent vital signs for the first 24 hours to rule out internal bleeding. \(2) Encourage early ambulation and soft diet to facilitate bowel elimination. \(4) Give analgesic before first bowel movement and sitz bath after for pain relief. \(5) Instruct patient to use cushion for sitting postoperatively. \(1) Etiology and Pathophysiology: A complex problem that has a variety of causes a. The external anal sphincter may be relaxed, the voluntary control of defecation may be interrupted in the central nervous system, or messages may not be transmitted to the brain because of a lesion within or external pressure on the spinal cord. b. The disorders that cause breakdown of conscious control of defecation include lesions of the cerebral cortex, spinal cord lesions or trauma, and trauma to the anal sphincter (e.g., from fistula, abscess, or surgery). c. Perineal relaxation and actual damage to the anal sphincter often are caused by injury from perineal surgery, childbirth, or anal intercourse. b\. Medical Management for Fecal Incontinence: 1. Biofeedback training is the cornerstone of therapy for patients who have motility disorders or sphincter damage that causes fecal incontinence. 2. Bowel training is the major approach used with patients who have cognitive and neurologic problems resulting from stroke or other chronic diseases 3. Have patient sit on a toilet, he or she may be able to defecate automatically given a pattern of consistent timing, familiar surroundings, and controlled diet and fluid intake. 4. Surgical correction is possible for a small group of patients whose incontinence is related to structural problems of the rectum and anus. c\. Patient Teaching: 1. To plan the most effective approach, gather specific information concerning the person's general physical and cognitive condition, ability to contract the abdominal and perineal muscles on command, and awareness of the need or urge to defecate. 2. Stress the importance of providing a high-fiber diet and ensuring that the patient has a sufficient fluid intake. 3. Evaluate the need for a regular stool softener or bulk former. When an optimal time for defecation has been established, usually after breakfast, a glycerin suppository may be inserted to stimulate defecation. \(4) Give analgesic before first bowel movement and sitz bath after for pain relief. \(5) Instruct patient to use cushion for sitting postoperatively.