Management of Patients With Intestinal and Rectal Disorders PDF

Management of Patients With Intestinal and Rectal Disorders Part I Constipation, Diarrhea, Irritable Bowel Syndrome, Inflammatory Bowel Disease  Constipation It is abnormal hardening of stools that make their passage difficult and sometimes painful, a decrease in...

Management of Patients With Intestinal and Rectal Disorders Part I Constipation, Diarrhea, Irritable Bowel Syndrome, Inflammatory Bowel Disease  Constipation It is abnormal hardening of stools that make their passage difficult and sometimes painful, a decrease in stool volume, or retention of stool in the rectum for prolonged period May caused by certain medication or associated with some diseases 2  Constipation Clinical Manifestations – Abdominal distention, pain,& pressure – Borborygmus “gurgling or rumbling sounds” – Headache, Fatigue, & decrease in appetite – Sensation of incomplete emptying – Straining at stool – Elimination of small volume, hard, dry stool 3  Complications – Hypertension – fecal Impaction (accumulated mass of dry feces cannot be expelled) – hemorrhoids – fissure – Megacolon (dilated and atonic colon that obstruct the passage of colon contents) 4  Constipation Medical Management – Treatment of the underlying cause – Routine exercises and bowel habit training – Daily 6-12 tea spoonful of unprocessed bran – Laxative if necessary “ – Propulsive motor activity medication – Avoid enema “for impaction” 5  Constipation Nursing Management – Health history interview – Patient education – Encourage adequate fluids intake and high fiber diet – Relieving anxiety – Avoid complication 6  Diarrhea It is increased frequency of bowel movement “more than 3/ day, increased amount of stool”more than 200g/day” and altered consistency of stool “looseness” Acute diarrhea is most often associated with infection and usually self-limiting Chronic diarrhea persist for longer period and return sporadically May caused by certain medications, certain diseases, and tube feeding 7  Diarrhea Clinical Manifestations – Increased frequency and fluid content of stool – Abdominal cramps & distention – anorexia, & thirst – Tenesmus (is the feeling of constantly needing to pass stools ) – If severe: dehydration & fluid and electrolytes imbalances 8  Diarrhea Medical Management – Controlling symptoms – Preventing complications – Treatment of the underlying cause – Antibiotics and Anti-inflammatory drugs – Antidiarrheal medications 9  Diarrhea Nursing Management – Health history and assessment – During episode encourage rest and low bulk liquids and foods – Avoid caffeine, carbonated beverages, and very hot and cold food – Prevent, fat, milk products, whole-grain products, and fresh fruits – Antidiarrheal medications as prescribed – IV fluids therapy & monitor dehydration – Perianal care 10   Irritable Bowel Syndrome Also known as “Spastic Colon”- a common disorder characterized by abdominal cramping, abdominal pain, bloating, constipation and diarrhea. Results from a functional disorder of the intestinal motility There is no evidence of inflammation or tissue changes (no anatomical changes) in the intestinal mucosa. More common in Women than Men  Factors of triggers include – Heredity, Psychological Stress, Depression, and Anxiety, High-fat diet, Irritating Foods, Alcohol and Smoking use.  Clinical Manifestations Alteration in bowel patterns Pain Bloating: Uncomfortable feeling of fullness, tightness, or swelling in the abdomen. Abdominal distention  Diagnostic Findings: Stool Studies Contrast Radiography Studies Barium Enema Colonoscopy  Medical & Nursing Management Medication management Complimentary medicine- a wide variety of health care practices that may be used along with standard medical treatment Dietary changes & Food diary Adequate fluid intake Avoid Alcohol, Caffeine and Smoking Relaxation techniques A healthy, high-fiber diet if constipated Prevention of dehydration is essential if there is diarrhea   Inflammatory Bowel Disease (IBD) Includes Crohn’s Disease (regional enteritis) and Ulcerative Colitis. These diseases have large peak at 20-30 years and a smaller peak at 60-70 years. IBD is mediated by both Genetic and Environmental factors (pesticides, food additives, tobacco, radiation) Allergies and Immune disorders had also been suggested as causes.  A. Crohn’s Disease  Is a chronic, recurrent inflammatory disease which involves any segment of the GI tract from mouth to anus but more common in the distal ileum 80% and ascending colon.  Characterized by transmural inflammation (extends through all layers).  Frequently leads to intestinal obstruction, fistula, and abscess formation.  As the disease progresses the lumen narrows.  Clinical Manifestations - Crohn’s Disease – Pain- right lower quadrant (RLQ) – Diarrhea – Scar tissue and formulation of granulomas – Abdominal tenderness and spasm – Weight loss, malnutrition, and secondary anemia may develop – Abscess, fissures and fistula  Chronic Symptoms: Diarrhea, abdominal pain, steatorrhea, anorexia, weight loss, and nutritional deficiencies. – Joint pain, skin lesions, and oral ulcers  Crohn’s Disease Assessment and Diagnostic Findings: – Proctosigmoidoscopy – Stoll Examination- Occult blood and Steatorrhea – Barium Study & CT scan – Video Capsule Endoscopy – Endoscopy, Colonoscopy, and Intestinal biopsies – CBC Complications: – Intestinal obstruction – Perianal disease – Fluid and electrolyte imbalance – Malnutrition from malabsorption  B. Ulcerative Colitis – A nonspecific inflammatory condition of the colon (unknown cause) and rectum. – Superficial ulcers seen in mucosa Bleed Become edematous Become abscessed causing reduced absorptive surface of the bowel – May be seen more with structured persons who tend to be perfectionistic.  Ulcerative Colitis- Manifestations Physical Psychosocial/Cultural – Frequent diarrhea – Occurs most often in – Stool with mucus, blood, Adolescents pus Young adults – Colicky abdominal – Causes depression, cramps, distention anger, frustration – Low grade fever – Stress may cause – Fluid and electrolyte exacerbation imbalance – Weight loss, anorexia – Weakness and cachexia  Ulcerative Colitis Assessment and Diagnosis – Assess for tachycardia, hyoptension, tachypnea, fever, and pallor – Assess hydration and nutritional status – Physical examination of abdomen – Assess stool for blood (+ve) & CBC – Abdominal X-ray, CT scan, MRI, or Ultrasound – Sigmoidoscopy, Colonoscopy, or Barium enema Complications: Toxic mega-colon, perforation, and bleeding as a result of ulceration, vascular engorgement, and highly vascular granulation tissue.  Management of Patients with IBD  Nutritional Therapy: Oral fluid, low-residue, high protein, high calorie diet, supplemental vitamin & iron replacement. Avoid food that exacerbate diarrhea; milk, cold foods  Pharmacologic Therapy: Sedatives, Antidiarrheal, & Antiperistaltic medications to rest inflamed bowel Aminosalicylates (Sulfasalazine), Antibiotics (Metronidazole), Corticosteroids (Prednisone)  Surgical: Strictureplasty, and intestinal transplant (newly developed), total colectomy with ileostomy.  Nursing Process: Inflammatory Bowel Disease—Assessment Health history to identify onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history. Discuss dietary patterns, alcohol, caffeine, and nicotine use Assess bowel elimination patterns and stool Abdominal Assessment  Nursing Process: IBD— Diagnoses Diarrhea Acute Pain Deficient Fluid Imbalanced Nutrition Activity Intolerance Anxiety Ineffective Coping Risk for Impaired Skin Integrity Risk for ineffective therapeutic regimen management  Complications: Electrolyte Imbalance Cardiac Dysrhythmias GI bleeding with fluid loss Perforation of the bowel  Nursing Process: IBD— Planning  Major goals may include: Attainment of normal bowel elimination patterns Relief of abdominal pain and cramping Prevention of fluid deficit Maintenance of optimal nutrition and weight Avoidance of fatigue Reduction of anxiety Promotion of effective coping Absence of skin breakdown Increased knowledge of disease process and therapeutic regimen Avoidance of complications Maintaining Normal Elimination Pattern Identify relationship between diarrhea and food, activities, or emotional stressors. Provide ready access to bathroom Encourage bed rest to reduce peristalsis Administer medications as prescribed Record frequency, consistency, character, and amounts of stools.  Other Interventions Assessment and treatment of pain or discomfort, Anticholinergic medications before meals, analgesics, positioning, diversional activities, and prevention of fatigue. Fluid Deficit, I&O, daily weight, assessment of symptoms of dehydration or fluid loss, encourage oral intake, measures to decrease diarrhea. Optimal Nutrition; elemental feedings that are high in protein and low residue or PN may be needed Reduce Anxiety, use a calm manner, allow patient to express feelings, listening, patient education  Patient Education Understanding of disease process Nutrition and diet Medications Information sources: National Foundation for Ileitis and Colitis Ileostomy care if applicable  Acute Inflammatory Intestinal Disorders  A. Appendicitis The appendix becomes – Inflamed, swollen, and gangrenous – It eventually perforates if not treated Appendicitis is related to intraluminal obstruction with – A fecalith (i.e., hard piece of stool) – Gallstones – Tumors – Parasites – Lymphatic tissue  Appendicitis Infectious and inflammatory process of of the appendix creating acute abdominal pain and nausea Common cause of acute abdomen, and the most common reason of emergency abdominal surgery Affect men more than women Most common in teenagers 29  Appendicitis Clinical Manifestations – Right lower quadrant pain – Pain location relate to appendix location – Low grade fever – Nausea and sometimes vomiting – Tenderness at McBurny’s point – Rebound & Rovsing signs may present – Abdominal distention and constipation 30  Appendicitis Medical Management – Appendectomy as soon as possible – Antibiotics and IV fluids for dehydration – Analgesic after Dx is made Complications – Perforation with incidence of 10-32% – Occur 24 hours after onset of pain – Symptoms include fever 37.7 or more, toxic appearance, abd pain & tenderness 31  Appendicitis Nursing Management – Pre operation preparation – Avoid enema – Post operation care V/S, and complication monitoring Semi-Fowler position Analgesics and pain killers IV fluids for dehydration Oral Fluids as tolerated Care for drain if present Home care education 32  B. Peritonitis Inflammation of the peritoneum, which is the serous membrane lining the abdominal cavity and covering the viscera. Usually bacterial, may be secondary to fungal infections Other causes – Injury or trauma – Other organ infections (e.g., kidney) – Appendicitis, Perforated ulcers, Diverticulitis – Bowel perforation – Abdominal surgical procedures – Peritoneal dialysis  Peritonitis  Manifestations: Depend on location and extent of inflammation S&S of infection Diffuse pain Rebound tenderness and paralytic ileus Anorexia, nausea, vomiting, and diminished peristalsis Low grade fever Assessment and findings- high WBCs, altered K, Na, and Cl, abdominal x-ray, ultrasound, and CT scan, MRI may be used – Peritoneal aspiration (C&S)  Peritonitis Complications – Widespread infection, sepsis, and shock – Intestinal obstruction (due to adhesions) Medical Management Fluid replacement Analgesia and antiemetic drugs Oxygen therapy to promote oxygenation Antibiotics Surgical treatment if necessary- excision, resection with or without anastomosis, repair (e.g., perforation), and drainage (e.g., abscess) Nursing Management- ICU care, continuous monitoring