Student Unit 1 Lecture 4 Low GI PDF

Absorption and Elimination Cynthia Lasman, RNC-OB, MSN, CNE, C-EFM [email protected] Objectives  Review anatomy and physiology of the lower GI system  Discuss common laboratory tests and diagnostic tools for lower GI system  Consider the etiology and incidence of lower GI di...

Absorption and Elimination Cynthia Lasman, RNC-OB, MSN, CNE, C-EFM [email protected] Objectives  Review anatomy and physiology of the lower GI system  Discuss common laboratory tests and diagnostic tools for lower GI system  Consider the etiology and incidence of lower GI disease and dysfunction  Describe common assessment findings with lower GI disease and dysfunction  Describe select conditions of the lower GI system  Explain appropriate nursing care and rationales for the care of patients experiencing lower GI disease and dysfunction A&P: Lower GI  Mind and emotions play a role in function  Small Intestine  Longest segment of the GI tract (2/3 of total)  Primary function is absorption  3 sections  Duodenum (ampulla of Vater – opening from the common bile duct)  Jejunum  Ileum (ends with the ileocecal valve – prevents bacteria from ascending)  Large Intestine  Ascending (right side)  Transverse (right to left across the upper abdomen  Descending (left side)  Sigmoid Colon  Rectum  Anus (internal and external sphincters to regulate output) Waste Products  Fecal matter should be 75% fluid and 25% solid  Brown color is from breakdown of bile by gut bacteria  GI tract contain gases formed from digestion  Absorbed by portal circulation  detoxified by the liver  Expelled from the rectum as flatus  Process of elimination  Rectal distention causes contractions of the musculature and relaxes the internal anal sphincter  External anal sphincter is under voluntary control  Contracting the abdominal muscles can aid in defecation Gut Microbiome  Breakdown waste  Vitamin synthesis  Immune functions (protective and inflammatory)  Colonization begins at birth and is established by 2 years old  Factors that influence the gut microbiome  Age  Genetics  Diet  Personal hygiene  Infection  Vaccinations  Chronic disease  Medication (especially antibiotics) Laboratory Studies  Serum laboratory studies  Stool tests  Ultrasonography  Genetic testing  Imaging studies: CT, PET, MRI, scintigraphy, virtual colonoscopy  Lower GI tract study  GI motility studies  Sigmoidoscopy / Colonoscopy Question Is the following statement true or false? When a colonoscopy is performed, the flexible scope is passed through the rectum and sigmoid colon into the descending, transverse, and ascending colon. Answer to Question True Rationale: When a colonoscopy is performed, the flexible scope is passed through the rectum and sigmoid colon into the descending, transverse, and ascending colon. When a flexible fiberoptic sigmoidoscopy is performed, the flexible scope is advanced past the proximal sigmoid and then into the descending colon. Constipation  Constipation  Fewer than three bowel movements weekly  bowel movements that are hard, dry, small, or difficult to pass  Common condition  Causes include many medications, chronic laxative use, weakness, immobility, fatigue, inability to increase intra- abdominal pressure, diet, ignoring urge to defecate, and lack of regular exercise  Perceived constipation: a subjective problem in which the person’s elimination pattern is not consistent with what he or she believes is normal  Chronic constipation is usually idiopathic  Diagnosis  Further testing for severe, intractable constipation  Thorough history and physical examination  Barium enema, sigmoidoscopy, and stool testing  Defecography and colonic transit studies  MRI Constipation  Assessment  Fewer than three bowel movements per week  Abdominal distention, pain, and bloating  A sensation of incomplete evacuation  Straining at stool  Elimination of small-volume, hard, dry stools  Complications  Decreased cardiac output  Fecal impaction  Hemorrhoids  Fissures  Rectal prolapse  Megacolon (dilated, atonic colon) Constipation  Management and Teaching  Correct underlying cause (may require change to pt’s medications)  Teach what is normal variations of bowel patterns  Establishment of normal pattern  Increase dietary fiber and fluid intake  Responding to the urge to defecate  Gastrocolic reflex  Support legs during defecation  Attempt bm after meals or a warm drink  Exercise and activity (abdominal toning)  Biofeedback therapy  Laxative use Table 41-1 Knowledge Check Which is an example of a laxative osmotic agent? A. Bisacodyl B. Docusate C. Magnesium hydroxide D. Polyethylene glycol and electrolytes ANSWER D. Polyethylene glycol and electrolytes Rationale: Polyethylene glycol and electrolytes is an osmotic agent. Bisacodyl is a stimulant laxative. Ducosate is an emollient stool softener. Magnesium hydroxide is a saline agent. Diarrhea  Increased frequency of bowel movements (more than three per day) with altered consistency (i.e., increased liquidity) of stool  Usually associated with urgency, perianal discomfort, incontinence, or a combination of these factors  May be acute, persistent, or chronic  Acute – self-limiting lasting 1-2 days (often viral)  Noninflammatory (large-volume)  Noninvasive enteric pathogens  Inflammatory (small-volume)  Pathogens that invade mucosa  Bloody stool (dysentery  Persistent – 2-4 weeks (often viral or related to medication)  Chronic – more than 4 weeks (often related to parasitic or c-diff infections, chemo, cardiac meds, or endocrine disorder, tube feeding formula, malabsorption, other conditions) Diarrhea  Assessment  Increased frequency and fluid content of stools  Abdominal cramps  Distention  Borborygmus  Anorexia and thirst  Painful spasmodic contractions of the anus  Tenesmus  Diagnosis  CBC  Serum chemistries  Urinalysis  Stool examination  Endoscopy or barium enema Diarrhea  Treatment  Supportive care  Antidiarrheal, antibiotics (not for viral infections), probiotics  Complications  Fluid and electrolyte imbalances  Dehydration  Cardiac dysrhythmias low K+  Chronic diarrhea can result in skin care issues related to irritant dermatitis  Teaching  Recognition of need for medical treatment  Rest  Diet and fluid intake  Avoid irritating foods, including caffeine, carbonated beverages, very hot and cold foods  Perianal skin care  Medications  May need to avoid milk, fat, whole grains, fresh fruit, and vegetables  Lactose intolerance  Fecal incontinence  Anal sphincter weakness  Traumatic (e.g., after surgical procedures involving the rectum) and nontraumatic (e.g., scleroderma)  Neuropathies both peripheral (e.g., pudendal) and generalized (e.g., diabetes)  Disorders of the pelvic floor (e.g., rectal prolapse)  Inflammation (radiation proctitis, IBD)  Central nervous system disorders (e.g., dementia, stroke, spinal cord injury, multiple sclerosis)  Diarrhea; fecal impaction with overflow  Behavioral disorders Fecal Incontinence  Assessment  Minor soiling to complete incontinence  Occasional urgency  Loss of control  Diagnosis  History to determine etiology  Rectal examination  Endoscopic examinations  Radiography studies  Treatment  Barium enema  Bowel training program  CT  Skin care  Anorectal manometry  Fecal management system (for acute illness)  Emotional support Irritable Bowel Syndrome (IBS)  Chronic functional  recurrent abdominal pain  associated with disordered bowel movements  may include diarrhea, constipation, or both  15% of adults in the United States report symptoms of IBS; More common in women than men (often concomitant with other disorders)  May be caused by neuroendocrine dysregulation leading to altered peristalsis  Triggers: chronic stress, sleep deprivation, surgery, infections, diverticulitis, and some foods  Irritable Bowel Syndrome (IBS)  Assessment  Teaching  Alteration in bowel patterns  Medication management  Pain  Complimentary medicine  Bloating  Dietary changes  Abdominal distention  Food diary  Diagnosis  Adequate fluid intake  Stool studies  Avoid alcohol and smoking  Contrast radiography studies  Relaxation techniques  Proctoscopy  Low FODMAP diet  Barium enema  Colonoscopy  Manometry  Electromyography  Rome IV criteria Malabsorption  The inability of the digestive system to absorb one or more of the major vitamins, minerals, or nutrients  Conditions  Mucosal (transport) disorders  Infectious disease  Luminal disorders  Postoperative malabsorption  Disorders that cause malabsorption of specific nutrients  Assessment  Hallmark finding is diarrhea or frequent, loose, bulky, foul-smelling stools, high-fat content, and often grayish  Symptoms similar to irritable bowel syndrome  Manifested by weight loss and vitamin and mineral deficiency Malabsorption  Diagnosis  Fat analysis  Lactose tolerance tests  D-xylose absorption tests  Schilling tests  Hydrogen breath test  Endoscopy with biopsy  Ultrasound, CT, radiography  CBC, pancreatic function tests  Teaching  Vitamin replacement  Dietary therapy  Probiotics  Consider fluid and electrolyte imbalance  Risk of osteoporosis Celiac Disease  Autoimmune disease with hereditary component  Assessment  Diarrhea, Steatorrhea  Constipation  Failure to thrive or weight loss  Abdominal distention or bloating  Poor muscle tone  Irritability and listlessness ◦Treatment  Dental disorders ◦ Strict gluten-free diet for life  Anemia ◦Interventions  Delayed onset of puberty or amenorrhea ◦ Dietary consult, support  Nutritional deficiencies Acute Abdomen  Also called “surgical abdomen”  Acute onset of pain without trauma that requires swift surgical intervention  Peritonitis – inflammation of the peritoneum  Usually bacterial  Primary – spontaneous infection (often with liver failure)  Secondary – follows perforation of abdominal organs  Tertiary – superinfection in immunocompromised patient  Diagnosis  WBC, CBC  Xray, CT, MRI  Peritoneal aspiration with culture and sensitivity Acute Abdomen  Treatment  Supportive care and control source of infection  Fluids  Medications: pain, antiemetic, antibiotic therapy (large dose, broad spectrum)  Nursing Care  Monitor closely for change in bowel function  Monitor closely for sepsis  Diverticular Disease  Diverticulum: sac-like herniation of the bowel lining that extends through a defect in the muscle layer  May occur anywhere in the intestine but most common in the sigmoid colon  Diverticulosis: multiple diverticula without inflammation  Diverticulitis: infection and inflammation of diverticula -problem  Diverticular disease increases with age and is associated with a low-fiber diet  Diagnosis is usually by colonoscopy or CAT scan Diverticular Disease  Assessment  May be mild with bowel irregularity and alternating constipation and diarrhea with nausea, anorexia and bloating/distention  With inflammation  Acute onset of mild to severe cramping pain in the LLQ  Constipation  Bloating with nausea, fever  With abscess (all above and…)  Bleeding  Tenderness  Palpable mass  Interventions  Encourage fluid intake of at least 2 L/day  Peritonitis  Soft foods with increased fiber, such as cooked vegetables  Individualized exercise program  Bulk laxatives (psyllium) and stool softeners Intestinal Obstruction  Intestinal obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract  Mechanical obstruction:  Intraluminal obstruction or mural obstruction from pressure on the intestinal wall  Functional or paralytic obstruction:  The intestinal musculature cannot propel the contents along the bowel  The blockage also can be temporary and the result of the manipulation of the bowel during surgery Intestinal Obstruction  Treatment  Decompression with NG tube insertion  25% require surgical intervention  Interventions  Maintaining the function of the nasogastric tube  Assessing and measuring the nasogastric output  Assessing for fluid and electrolyte imbalance  Monitoring nutritional status, and  Assessing for manifestations consistent with resolution (e.g., return of normal bowel sounds, decreased abdominal distention, subjective improvement in abdominal pain and tenderness, passage of flatus or stool) Knowledge Check Is the following statement true or false? The most common site for diverticulitis is the ileum. ANSWER False Rationale: The most common site for diverticulitis is not the ileum. The most common site for diverticulitis is the sigmoid.  Inflammatory Bowel Disease (IBD)  Group of chronic disorders  Crohn’s disease (regional enteritis)  Ulcerative colitis  Refer to Table 41-5 to compare  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 Crohn’s Disease (regional enteritis)  Subacute and chronic inflammation of the GI tract wall through all layers  Most commonly occurs in the distal ileum and ascending colon  Disease progression  Begins as inflammation, progresses to abscesses, then ulcers and scarring  Creates cobblestone appearance  Skip lesions  Narrowing of the bowel lumen (thickened walls)  Adhesions  Assessment  Diarrhea and RLQ pain (unrelieved by defecation)  Crampy abdominal pain, tenderness (after meals)  Weight loss, malnutrition, anemia (food avoidance)  Ulcerative Colitis  Chronic ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum  Disease progression  Periods of remission and exacerbations typically starting in the rectum and progressing proximally through the colon  Assessment  Abdominal cramps with bloody or purulent diarrhea  Bleeding is from ulcerations (continuous lesions)  LLQ pain  Pallor, anemia, fatigue  Anorexia, weight loss, fever, vomiting  Probiotics may be part of treatment  Toxic megacolon can occur Knowledge Check Is the following statement true or false? Fistulas are common in Crohn’s disease. ANSWER True Rationale: Perianal involvement, fistulas, and abdominal mass are common in Crohn’s disease. Inflammatory Bowel Disease (IBD)  Complications  Goals  Electrolyte imbalance  Attainment of normal bowel  Cardiac dysrhythmias elimination patterns  GI bleeding with fluid loss  Relief of abdominal pain and  Perforation of the bowel cramping  Prevention of fluid deficit  Treatment  Maintenance of optimal nutrition  Nonsurgical and weight  Medications  Avoidance of fatigue  Nutritional Therapy  Reduction of anxiety  Surgical  Promotion of effective coping  1/3 of pts with severe UC (dysplasia or  Absence of skin breakdown cancer)  Nearly 2/3 of pts with Crohn’s  Increased knowledge of disease (obstruction) process  Also may be needed with abscess,  Therapeutic regimen perforation, hemorrhage, fistula  Avoidance of complications IBD Nursing Interventions  Maintaining normal elimination patterns (longer periods of remission)  Identify relationship between diarrhea and food, activities, or emotional stressors  Provide ready access to bathroom or commode  Encourage bed rest to reduce peristalsis  Administer medications as prescribed  Record frequency, consistency, character, and amounts of stools  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 IBD Patient Education  Understanding of disease process  Nutrition and diet  Medications  Information sources: National Foundation for Ileitis and Colitis  Ileostomy care if applicable Anorectal Conditions  Proctitis – inflammation of the mucosa of the rectum  Often secondary to other conditions, STIs, or procedures  Treated with antibiotics if infectious  Anorectal abscess – caused by obstruction of an anal gland with dried debris  More common with Crohn’s or immunosuppression  Treated with prompt surgical intervention (incise and drain)  Anal fistula – tubular, fibrous tract into the anal canal from the perianal skin  Usually secondary to abscess, trauma, fissures, Crohn’s  Surgical fistulectomy in most cases  Anal fissure – longitudinal tear or ulceration in the lining of the any canal  Caused by trauma  Treatment with modified diet and topical therapies (surgery if needed) Anorectal Conditions  Hemorrhoids – dilated veins in the anal canal  10 million people have this in the U.S.  May be internal or external  Treated with good hygiene, high-residue diet, laser therapy, injection of sclerosing agents  Surgical treatments – rubber band ligation, stapled hemorrhoidopexy, hemorrhoidectomy/excision  Pilonidal sinus or cyst – in the intergluteal cleft  May result from trauma causing hairs to penetrate the epithelium  Can be congenital  Usually no symptoms until adolescence  Infection results in abscess or drainage  Incision and drainage with local anesthesia Anorectal Conditions  Assessment  Health history  Pruritus, pain, or burning  Elimination patterns  Diet  Exercise and activity  Occupation  Inspection of the area  Major goals may include:  Adequate elimination patterns  Reduction of anxiety  Pain relief  Promotion of urinary elimination  Management of the therapeutic regimen  Absence of complications  Nursing Interventions  Encourage intake of at least 2 L of water a day  Recommend high-fiber foods  Bulk laxatives, stool softeners, and topical medications  Promote urinary elimination  Hygiene and sitz baths  Monitor for complications  Educate on self-care Review of Objectives Review anatomy and physiology of the lower GI system Discuss common laboratory tests and diagnostic tools for lower GI system Consider the etiology and incidence of lower GI disease and dysfunction Describe common assessment findings with lower GI disease and dysfunction Describe select conditions of the lower GI system Explain appropriate nursing care and rationales for the care of patients experiencing lower GI disease and dysfunction