NUR355_Module 8_Intestinal Disorders.pdf

Acute & Chronic Health Disruptions in Adults l Module 8 – Gastrointestinal Coordinating Care for Patients with Intestinal Disorders Chapter 58  Abdominal Trauma Common: liver laceration, ruptured spleen, mesenteric artery tears, diaphragm rupture, urinary bladder rup...

Acute & Chronic Health Disruptions in Adults l Module 8 – Gastrointestinal Coordinating Care for Patients with Intestinal Disorders Chapter 58  Abdominal Trauma Common: liver laceration, ruptured spleen, mesenteric artery tears, diaphragm rupture, urinary bladder rupture, great vessel tears, renal or pancreas injury, stomach or intestine rupture Blunt: MVA, direct blows, and falls Penetrating: knife or gunshot Spleen and liver are most common organs affected  Abdominal Trauma Concerns Hypovolemic shock: hemorrhage from solid organs Peritonitis: hollow organ spills contents Abdominal compartment syndrome Clinical Manifestations Varies; Depends on organ of injury Classic  Guarding and splinting abdomen  Hard, distended abdomen  Decreased or absent bowel sounds  Abrasions or bruising; Cullen’s or Grey Turner’s sign  Abdominal pain  Hematemesis or hematuria  Signs of hypovolemic shock  Abdominal Trauma Diagnostics Baseline labs: CBC, urinalysis Other: ABGs, prothrombin time, electrolytes, BUN, creatinine, and type and crossmatch FAST exam (focused abdominal sonography for trauma) Diagnostic peritoneal lavage (DPL) Management Large bore IV access and fluids Complications NG tube Hemorrhagic shock Peritonitis Monitor for ARDS  Deterioration of condition DIC  Need for surgery Do not remove impaled object Exploratory laparotomy  Intestines The main functions of the intestinal system are digestion, absorption, and elimination of waste products. Small Intestine Duodenum—attaches to the pylorus and is approximately 10 inches Jejunum—approximately 8 feet Ileum—approximately 12 feet Large Intestine (approx. 5-6 feet) – 3 parts Cecum Colon  Ascending colon  Transverse colon  Descending colon  Sigmoid colon Rectum  Bowel/Intestinal Obstruction Occurs when intestinal contents cannot pass through the GI tract Small bowel (SBO) or large bowel (LBO) Causes: SBO  75% - conservative tx LBO  25% - typically requires surgery Adhesions related to surgery Adhesions related to surgery Malignancy (tumors) Malignancy (tumors) Hernia Incarcerated hernia Volvulus (twisting) Strictures Intussusception Diverticular disease Gallstones Benign polyps Volvulus (twisting) Intussusception  Bowel/Intestinal Obstruction Types Mechanical – physical obstruction  Adhesions, strangulated hernias, strictures, tumors, fecal impaction Non-mechanical – aka neurogenic; reduced or absent peristalsis common after bowel surgery, peritoneal irritation, or intestinal ischemia  Paralytic ileus: bowel surgery, peritonitis, inflammatory disorders, electrolyte imbalances, thoracic, or lumbar spinal fractures Bowel/Intestinal Obstruction A. Adhesions, B. Strangulated inguinal hernia, C. Ileocecal intussusception, D. Intussusception from polyp, E. Mesenteric occlusion, F. Neoplasm, G. Volvulus  Bowel/Intestinal Obstruction Partial: some contents get through (fluid/gas)  conservative tx Complete: total occlusion  surgery Simple: intact blood supply Strangulated: no blood supply  Ischemia results in necrosis and perforation  Blood flow stops Partial Complete – Edema – Cyanosis – Gangrene – Infection, septic shock and death  Pathophysiology Bowel/Intestinal Obstruction 6-8 L of fluid daily OBSTRUCTION Distal Small bowel Proximal Distal to obstruction, the bowel 75% of intestinal gas empties, and then collapses is swallowed air Most of the fluid is Fluid, gas, and intestinal absorbed before contents accumulate reaching the colon Distal to obstruction, the bowel proximal to the obstruction. empties, and then collapses Intestinal muscle becomes Distention  reduced fluid ↑ pressure  ↑capillary fatigued, peristalsis stops. Hypotension and absorption  initially stimulates permeability  Retention of fluid in hypovolemic shock intestinal secretions extravasation of F&E  peritoneal cavity  severe Distention  ↑ bowel pressure leaks into peritoneal decrease in circulating volume cavity  Bowel/Intestinal Obstruction Abdominal distension proximal to obstruction Pain: sharp, cramping, intermittent d/t hyperactive peristalsis N/V  fluid/electrolyte imbalances Partial obstruction  diarrhea No dehydration or electrolyte A patient with a bowel imbalances early on Duodenum obstruction  metabolic obstruction c/o of Obstruction in proximal colon: no alkalosis from vomiting, NG suction increased pain = poss symptoms until fecal material Small intestine obstruction  rapid perforation accumulates dehydration  Bowel/Intestinal Obstruction 4 Hallmark Clinical Manifestations Diagnostics Treatment Abdominal pain H&P NPO Nausea/Vomiting Abd x-ray NGT to suction (decompression) CT IV Fluids (with K, to replace loss Distention Barium enema during NG suction) Constipation Sigmoidoscopy or *The order and degree these appear vary by Pain management the cause, location, and type of obstruction colonoscopy Antiemetics CBC, electrolytes Antibiotics Surgical Management Complete obstructions  surgery Complications Laparoscopic Intestinal perforation, bacteremia, sepsis, intra- Exploratory laparotomy abdominal abscess, pneumonia with aspiration, Colectomy dehydration, electrolyte imbalances, and acid–balance Colostomy – permanent or temporary disturbances  Irritable Bowel Syndrome (IBS) Pathophysiology Cause is unknown Mucosal lining of the bowel remains essentially unchanged with symptoms Abdominal pain and altered bowel habits for which no other cause can be found Females > males No cure Four subtypes of IBS IBS-C (constipation dominant) IBS-D (diarrhea dominant) IBS-M (mixed, or alternating from diarrhea to constipation) IBS unclassified (meets IBS diagnostic criteria but cannot be accurately categorized) Irritable bowel syndrome is characterized by areas of bowel spasm and dilation.  Irritable Bowel Syndrome (IBS) Clinical Manifestations Diagnosis Diarrhea Based solely on symptoms Constipation Rome IV criteria Flatus IBS is categorized by stool patterns Abdominal pain Symptoms Other: nausea, flatulence, Health history including psychosocial factors mucus in stool, sensation Family history of incomplete evacuation Drug history Non-GI symptoms: Diet history Fatigue, headache, and Impact on activities/life sleep problems Diagnostic tests: rule out other disorders  IBS Management Focus: controlling spasm, minimizing diarrhea, releasing neurotransmitters to promote peristalsis, and addressing depression No single effective therapy Psychologic support Cognitive behavior; stress management Dietary changes: Gluten free, high fiber, FODMAP diet (Fermentable oligosaccharides, disaccharides, monosaccharides and polyols) Drugs to regulate stool and reduce pain Antispasmodics, antidepressants, antidiarrheals, or laxatives *Diarrhea may lead to fluid volume deficit Teaching Avoid trigger foods Keep a food diary Consume regular meals and drink adequate water Encourage regular exercise Smoking cessation Referral: Dietician, psychological counseling, support groups Inflammatory Bowel Disease Crohn’s Disease & Ulcerative Colitis  Inflammatory Bowel Disease Chronic inflammation of GI tract. Periods of remission and periods of exacerbation. Pathophysiology Exact cause is unknown  Autoimmune disease  Environmental factors  Drug associations  Genetic link Inappropriate response in intestinal tract causing inflammation Classifications Ulcerative colitis: colon Crohn’s disease: anywhere in GI tract Crohn’s Disease Can affect any portion of GI tract  mouth to anus “Skip” lesions – normal tissue between areas of inflammation All layers of bowel wall – leading to fistulas, abscesses, peritonitis Cobblestone appearance from deep ulcerations Strictures – bowel obstruction Leaks – abscess formation in peritoneal cavity Fistulas common Clinical Manifestations Diarrhea, cramping (less severe than UC) Weight loss Abdominal pain Steatorrhea (fatty stools) Fever Fatigue Some bleeding may occur  Ulcerative Colitis Involves colon; starts in rectum spreads to cecum Mucosal layer (innermost) Diarrhea and electrolyte loss: can’t absorb through inflamed tissue Protein loss in stool Pseudopolyps form: tongue-like projections into bowel Clinical Manifestations Diarrhea, bloody  Mild = fewer than 4 stools/day  Moderate = up to 10 stools/day  Malaise, anemia, anorexia  Severe = 10 to 20 stools/day  Anemia, tachycardia, dehydration Stool with mucus and pus ↓Hgb/Hct Weight loss, abdominal pain, tenesmus Fever Fatigue  Crohn’s & UC Complications Complications Hemorrhage Strictures Perforation (with possible peritonitis) Perineal abscesses Fistulas (between bowel and bladder are common with Crohn’s) C diff infection Colonic dilation (toxic megacolon) High risk for colorectal cancer  Inflammatory Bowel Disease Treatment Teaching Goals of treatment of IBD Fluid and electrolyte management Encourage smaller frequent meals  Rest the bowel Rest Encourage pt to engage in mealtime with family  Control inflammation Medications Encourage periods of rest  Treat infection Nutrition – may need TPN, Importance of adequate nutrition  Correct malnutrition vitamins Indications, actions, and side effects of  Alleviate stress CAM – ex. marijuana, turmeric, prescribed medications  Relieve symptoms curcumin, fish oil, probiotics Importance of regular follow-ups and annual  Improve quality of life Psychosocial management colonoscopy Surgical management Perianal skin care Diagnosis  Drug selection depends on severity and location of inflammation Colonoscopy  Step-up approach Sigmoidoscopy  Step-down approach Barium enema  Goals of drug treatment: induce and maintain remission  5- Amino salicylates (5-ASA)  Antimicrobials Table 58.4 Medications Used  Corticosteroids in the Treatment of  Immunosuppressants Inflammatory Bowel Disease  Biologic and targeted therapy  Surgical Therapy: Ulcerative Colitis Indications: Depends on severity Procedures: – Total proctocolectomy with ileal pouch/anal anastomosis (IPAA) – Total proctocolectomy with permanent ileostomy – Surgery is curative Ileoanal Pouch Formation  Surgical Therapy: Crohn’s Disease Generally done for complications Most common: resect diseased sections with reanastomosis; often recur  Repeated surgeries result in short bowel syndrome  Difficult to maintain hydration and nutrition Strictureplasty: opens narrowed areas  Celiac Disease Autoimmune disease – Immune reaction to gluten causing small intestine inflammation Wheat, barley, and rye Hair and skin care products Associated with other autoimmune disorders  Rheumatoid arthritis, type I diabetes, thyroid disease Cause – 3 factors : Genetic predisposition Gluten ingestion Immune-mediated response Causes inflammation which leads to damage to the intestinal villi, lengthening of intestinal cysts, and mucosal lesions.  Celiac Disease Clinical Manifestations Related to Mucosal Damage  Diarrhea (foul smelling, light in color, frothy)  Steatorrhea  Flatulence  Weight loss  Weakness  Other signs of malabsorption  Severe: severe abd pain, increased bleeding tendencies Atypical symptoms Anemia Dental enamel defects Osteoporosis Arthritis Peripheral neuropathies Infertility  Celiac Disease Diagnostics H&P Endoscopy with small bowel biopsy Screening for antibodies Labs: CBC, electrolytes, coags, LFTs Treatment Lifelong adherence to gluten-free diet Identify and treat malnutrition Consult dietitian Education about the disease Access support groups Continue management through interdisciplinary team Teaching Use dishwasher Diet adherence Read food labels Gluten-free resources  Diverticulosis and Diverticulitis Diverticula: a small, pouchlike protrusion or herniation, most often occurring in the gastrointestinal tract, particularly the colon  Common in older adults (occurs in 30%–50% of adults over age 60) Diverticulosis – the presence of diverticula that are noninflamed Diverticulitis – an inflammation of and/or infected diverticula Diverticulosis risk factors: Increasing age Obesity Smoking Low-fiber diet Heredity Medications (NSAIDs, acetaminophen, oral corticosteroids, and opiates).  Diverticulosis and Diverticulitis Clinical Manifestations Diagnosis Diverticulosis: most asymptomatic Abdominal x-ray  Abdominal pain, bloating, flatulence, CT (definitive) changes in bowel habits; Colonoscopy, Diverticulitis sigmoidoscopy  Acute pain in LLQ, distention, decreased or WBC absent bowel sounds, nausea, vomiting, UA systemic symptoms of infection (leukocytosis), palpable mass; diarrhea or constipation  Older adults: afebrile, normal WBC, possible abdominal tenderness, increased confusion, falling, and anorexia Complications Erosion of bowel wall and perforation, abscess, peritonitis, bleeding Diverticulosis and Diverticulitis Treatment Diverticulitis  Outpatient: Antibiotics, clear diet advance as tolerated  Hospital: NPO, IV fluids, NGT, IV antibiotics, pain management Surgical Management Indicated for perforation, obstruction, abscess formation, fistula formation Surgical resection with anastomosis or temporary colostomy Teaching Diverticulosis – high fiber (to prevent straining/constipation) Acute diverticulitis – low fiber Avoid increased intraabdominal pressure (straining, bending, lifting) Weight reduction Complete antibiotic therapy as prescribed  Appendicitis Vermiform Appendix A small hollow appendage that extends off the cecum Made of lymphatic tissue No known function Appendicitis Causes Fecalith or other foreign body blocking the opening Malignant tumors Twisting/kinking of appendix Bowel wall edema Adhesions Other infections No particular risk factors or preventive measures  Appendicitis Pathophysiology Diagnostics Opening to appendix becomes blocked CT scan, US, MRI Mucosa secretes fluid Venous engorgement Treatment Restricted blood flow Surgery to avoid rupture; peritonitis IV fluid & antibiotics Clinical Manifestations Initially dull periumbilical pain; anorexia, nausea, vomiting Persistent pain RLQ at McBurney’s point Fever, localized tenderness, rigidity, rebound tenderness, muscle guarding Complications ↑pain with cough, sneeze, deep breath Gangrene (24-36 hrs) A sudden ↓pain may indicate rupture in appendix Perforation (24 hrs) Older adult: less pain, slight fever, right iliac fossa Peritonitis discomfort Appendicitis Interventions NPO IV fluids (pre/post- op) Prepare patient for surgery Comfort measures Positioning: supine with HOB 30-45 degrees with knees flexed or side- lying with knees flexed Advance diet as tolerated post- procedure Teaching Turn, cough, deep breathe Incentive spirometer Early ambulation Complete antibiotics 34  Colorectal Cancer (CRC)  3rd most common form of cancer  2nd leading cause of death is United States Pathophys Most tumors are adenocarcinomas Metastasis Men > women Risk Factors Heredity (1st degree relatives; 5-10% of all colorectal cancers) Hx adenomatous polyps IBD (esp. UC >10 yrs) Physical inactivity Obesity Diet high in red meat  Colorectal Cancer Clinical Manifestations Early – asymptomatic Unexplained weight loss, fatigue Changes in bowel regularity and/or the appearance of stool Blood in the stool Abdominal pain and/or distention Sensation of pressure as with incomplete evacuation after a bowel movement Signs of anemia 38  Colorectal Cancer Diagnosis Colonoscopy (*gold standard) Serum carcinoembryonic antigen (CEA) CBC Abdominal x-ray CT, MRI  Colorectal Cancer Treatment CRC Staging Metastasis Chemotherapy Radiation therapy Surgical Management Colectomy Hemicolectomy Abdominoperineal resection Ostomy – temporary or permanent Goals of surgery  Complete resection of tumor  Thorough exploration of abdomen  Removal of all lymph nodes that drain the area  Restoration of bowel continuity  Prevention of surgical complications 40  Colorectal Cancer Nursing Management – Preop Bowel prep Consent Nursing Management – Postop Vital signs Labs: CBC, Hgb/Hct Bowel sounds NPO, NGT Intake/output New Ostomy Slight bleeding from the stoma initially is expected Surgical incision S/S ischemia (dark red, purplish, or black color) or Drain care unusual bleeding  call provider immediately Ostomy assessment Inspect skin around the ostomy site frequently Ostomy will begin to function within 2 to 4 days postop and care Empty gas from appliance Pain management Empty appliance when 1/3 to 1/2 full Pulmonary hygiene Stool appearance is initially liquid Referrals 41  Hernias Protrusion of intestine through an opening or weakened area in the cavity wall Reducible: easily return to abdominal cavity Irreducible or incarcerated: cannot be placed back into abdominal cavity; abdominal contents are trapped  Strangulated Risk Factors Obesity Smoking Excessive wound tension Malnutrition Pregnancy Medications Causes may include: Straining, lifting heavy objects, sudden twists, pulls or muscle strain, weight gain, chronic cough  Hernias Can occur anywhere in the body; it most frequently occurs in the abdominal cavity Clinical Manifestations Pain Bulge or visible swelling Strangulated: severe abd pain and distention, N/V, fever, tachycardia Diagnosis Physical exam Herniography Ultrasound, CT scan, MRI  Hernias Surgical Management Non-Surgical Management Surgical repair; laparoscopic Truss/binder Herniorrhaphy – hernia repair Hernioplasty: reinforce weak are with wire, fascia or mesh Strangulated: emergency surgery; temporary colostomy Post-Op Care Complications Monitor voiding; I&O Strangulation of intestine Scrotal edema: ice and elevation Recurrence Encourage deep breathing, splinting Coughing discouraged No heavy lifting (greater than 10 pounds) 6 to 8 weeks Pain management Clear liquid diet and advance as tolerated Early ambulation  Hemorrhoids Pathophys Swollen or dilated veins in the anorectal area Internal or External Increased anal pressure and weakened connective results in downward displacement Risk factors: Pregnancy Constipation Diagnosis Straining Internal: Digital Diarrhea examination, anoscopy, Heavy lifting sigmoidoscopy Prolonged External: Visual standing/sitting inspection Obesity Ascites  Hemorrhoids Clinical Manifestations Internal: bleeding with defecation; pain, prolapse (pressure, protruding mass) External: itching, burning, edema Treatments External: conservative Internal: rubber band ligation, infrared coagulation, sclerotherapy, laser treatment Complications Hemorrhoidectomy: surgical excision; Done with prolapse Infection or thrombosis Pain Ointments, creams, suppositories, impregnated pads, Urinary retention astringents, anesthetics, stool softeners Fecal impaction Damage to sphincter Bleeding Abscess formation  Hemorrhoids Postoperative Teaching Analgesia prior to first bowel Care of surgical site movement after surgery Measures to prevent constipation (high-fiber diet, Local anesthetics increased fluids) Corticosteroids Avoid straining Provide cold packs and sitz baths Avoid stimulant laxatives Administer laxatives Nonpharmacologic methods of reducing pain Apply local moist heat (not during When to contact healthcare provider immediate post op period)