Chapter 045 - Summary Medical-Surgical Nursing PDF

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LOWER GI PROBLEMS...

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Lewis: Medical-Surgical Nursing in Canada, 4th Edition Chapter 45: Nursing Management: Lower Gastro-Intestinal Problems Key Points DIARRHEA • Diarrhea—the frequent passage of loose, watery stools—is not a disease but a symptom. •

Causes of diarrhea can be divided into general classifications of decreased fluid absorption, increased fluid secretion, motility disturbances, or a combination of these.

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All cases of acute diarrhea should be considered infectious until the cause is known.

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Patients receiving antibiotics (e.g., clindamycin [Dalacin C]) are susceptible to Clostridium difficile (C. difficile), which is a serious bacterial infection.

FECAL INCONTINENCE • Fecal incontinence, the involuntary passage of stool, occurs when the normal structures that maintain continence are disrupted. •

Risk factors include constipation, diarrhea, and fecal impaction (an accumulation of hardened feces in the rectum or the sigmoid colon that the individual is unable to move).

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Prevention and treatment of fecal incontinence may be managed by implementing a bowel training program.

CONSTIPATION • Constipation can be defined as a decrease in the frequency of bowel movements from what is “normal” for the individual; hard, difficult-to-pass stools; a decrease in stool volume; retention of feces in the rectum; or some combination of these. •

Hemorrhoids, or dilated hemorrhoidal veins or varicosities, are the most common complication of chronic constipation. They result from venous engorgement caused by repeated executions of the Valsalva manoeuvre (straining) and venous compression from hard impacted stool.

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The overall goals for the patient with constipation are to increase dietary intake of fibre and fluids; have the passage of soft, formed stools; and not have any complications, such as bleeding hemorrhoids.

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An important role of the nurse is teaching the patient the importance of dietary measures to prevent constipation.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

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ACUTE ABDOMINAL PAIN • Acute abdominal pain is a symptom of many different types of tissue injury and can include conditions related to inflammation, peritonitis, obstruction, and internal bleeding. •

Pain is the most common symptom of an acute abdominal problem.

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The overall goals of management are that the patient with acute abdominal pain will have (1) resolution of the underlying process, (2) relief of abdominal pain, (3) freedom from complications (especially hypovolemic shock), and (4) normal nutritional status.

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Bowel sounds that are diminished, absent, or hyperactive in a quadrant may indicate a complete bowel obstruction, acute peritonitis, or paralytic ileus.

ABDOMINAL TRAUMA • Injuries to the abdominal area most often occur as a result of blunt trauma (e.g., motor vehicle accident) or penetration injuries, primarily gunshot wounds or stab wounds to the abdomen. Blunt trauma is most common. Regardless of whether it is a blunt or penetration injury, the result is often the same: damage to or alteration of the internal organs. •

Common injuries of the abdomen include lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears, diaphragm rupture, urinary bladder rupture, great vessel tears, renal injury, and stomach or intestinal rupture.

CHRONIC ABDOMINAL PAIN •

Chronic abdominal pain may originate from abdominal structures or may be referred from a site with the same or a similar nerve supply.

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Common causes of chronic abdominal pain include irritable bowel syndrome (IBS), diverticulitis, peptic ulcer disease, chronic pancreatitis, hepatitis, cholecystitis, pelvic inflammatory disease, and vascular insufficiency.

IRRITABLE BOWEL SYNDROME • Irritable bowel syndrome (IBS) is a chronic functional disorder characterized by intermittent and recurrent abdominal pain associated with an alteration in bowel function (diarrhea or constipation or both). Other symptoms commonly found include abdominal distension, excessive flatulence, bloating, urge to defecate, urgency, and sensation of incomplete evacuation. •

Neurological hypersensitivity within the GI (enteric) nerves, physical and/or emotional stress, dietary issues such as food allergies or sensitivities, antibiotic use, Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

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GI infection, bile acid malabsorption, chronic alcohol abuse, abnormalities in GI secretions and/or digestive muscle contractions (peristalsis), acute infection or inflammation of the intestine (enteritis) have been identified as factors that precipitate IBS symptoms.

INFLAMMATORY DISORDERS APPENDICITIS • Appendicitis is an inflammation of the appendix, a narrow blind tube that extends from the inferior part of the cecum. •

The most common causes of appendicitis are occlusion of the appendiceal lumen by a fecalith (accumulated feces) and intramural thickening caused by hypergrowth of lymphoid tissue. Obstruction results in edema, venous engorgement, and the invasion by bacteria, which can lead to gangrene and perforation.

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Appendicitis typically begins with periumbilical pain, followed by anorexia, nausea, and vomiting. The pain is persistent and continuous, eventually shifting to the right lower quadrant and localizing at the McBurney point.

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Until a health care provider sees the patient, nothing should be taken by mouth (NPO) to ensure that the stomach is empty in the event that surgery is needed.

PERITONITIS • Peritonitis results from a localized or generalized inflammatory process of the peritoneum. •

Abdominal pain is the most common symptom of peritonitis. A universal sign of peritonitis is tenderness over the involved area. Rebound tenderness, muscular rigidity, and spasm are other major signs of irritation of the peritoneum.

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Assessment of the patient’s abdominal pain, including the location, is important and may help in determining the cause of peritonitis.

GASTRO-ENTERITIS • Gastro-enteritis is an inflammation of the mucosa of the stomach and small intestine. • Clinical manifestations include nausea, vomiting, diarrhea, abdominal cramping, and distension. Most cases are self-limiting and do not require hospitalization. • If the causative agent is identified, appropriate antibiotic and antimicrobial drugs are given. • Symptomatic nursing care is given for nausea, vomiting, and diarrhea. Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

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INFLAMMATORY BOWEL DISEASE • Inflammatory bowel disease (IBD) is an autoimmune disease that currently refers to two disorders of the GI tract (Crohn’s disease and ulcerative colitis [UC]) characterized by idiopathic inflammation and ulceration. • IBD is characterized by mild to severe acute exacerbations that occur at unpredictable intervals over many years. Both diseases can be debilitating. ULCERATIVE COLITIS • Ulcerative colitis (UC) is a chronic IBD characterized by inflammation and ulceration of the rectum and the colon. • Ulcerative colitis usually starts in the rectum and moves in a continual fashion toward the cecum. Although there is sometimes mild inflammation in the terminal ileum, ulcerative colitis is a disease of the colon and rectum. • The overall goals are that the patient with UC will (1) respond to medical management, (2) maintain normal fluid and electrolyte balance, (3) be free from pain or discomfort, (4) participate in medical and surgical management, and (5) maintain nutritional balance.

CROHN’S DISEASE • Crohn’s disease is a chronic IBD of unknown origin that can affect any part of the GI tract from the mouth to the anus. • It occurs most commonly in the terminal ileum and colon. The inflammation involves all layers of the bowel wall with segments of normal bowel occurring between diseased portions (skip lesions). • With Crohn’s disease, diarrhea and colicky abdominal pain are common symptoms. If the small intestine is involved, weight loss occurs due to malabsorption. In addition, patients may have systemic symptoms such as fever. The primary symptoms of ulcerative colitis are bloody diarrhea and abdominal pain. •

Nutritional problems are especially common with Crohn’s disease when the terminal ileum is involved.

Treatment of IBD • The goals of treatment for IBD include resting the bowel, controlling the inflammation, combating infection, correcting malnutrition, alleviating stress, providing symptomatic relief, and improving quality of life. •

The following major classes of medications are used to treat IBD: o Aminosalicylates Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

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Antimicrobials Corticosteroids Immuno-suppressants Biological drug therapies

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Surgery is indicated if the patient with IBD fails to respond to treatment; exacerbations are frequent and debilitating; massive bleeding, perforation, strictures, and/or obstruction occur; tissue changes suggest that dysplasia is occurring; or carcinoma develops.

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During an acute exacerbation of IBD, nursing care is focused on hemodynamic stability, pain control, fluid and electrolyte balance, and nutritional support.

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Nurses and other team members can assist patients to accept the chronicity of IBD and learn strategies to cope with its recurrent, unpredictable nature.

AGE-RELATED CONSIDERATIONS • Although IBDs are considered diseases of young adults, a second peak in the distribution of these inflammatory conditions occurs around the ages of 50 to 70 years. •

In older-adult patients with UC, the distal colon is usually involved (proctitis). In older adults with Crohn’s disease, the colon rather than the small intestine tends to be involved.

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Because of increased risk for cardiovascular and pulmonary complications, older adults tend to have increased morbidity associated with surgical procedures.

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The loss of fluid and electrolytes and possibly blood may leave older adults more vulnerable to problems related to volume depletion and dehydration.

MALABSORPTION SYNDROME •

Malabsorption results from impaired absorption of fats, carbohydrates, proteins, minerals, and vitamins.

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Causes of malabsorption include the following: o Biochemical or enzyme deficiencies o Bacterial proliferation o Disruption of small intestine mucosa o Disturbed lymphatic and vascular circulation o Surface area loss

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The most common clinical manifestation of malabsorption is steatorrhea (bulky, foul-smelling, yellow-grey, greasy stools with putty-like consistency). Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

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CELIAC DISEASE • Celiac disease is an autoimmune disease characterized by damage to the small intestinal mucosa from the ingestion of wheat, barley, and rye in genetically susceptible individuals. •

Three factors necessary for developing celiac disease (also known as celiac sprue, or gluten-sensitive enteropathy) are genetic predisposition, gluten ingestion, and an immune-mediated response.

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Classical signs of celiac disease include foul-smelling diarrhea, steatorrhea, flatulence, abdominal distension, and symptoms of malnutrition.

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Individuals with celiac disease have an increased risk for non-Hodgkin’s lymphoma and GI cancers.

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Celiac disease is treated with lifelong avoidance of dietary gluten. Wheat, barley, oats, and rye products must be avoided.

LACTASE DEFICIENCY • Lactase deficiency is a condition in which the lactase enzyme is deficient or absent. Lactase is the enzyme that breaks down lactose into two simple sugars—glucose and galactose. •

The symptoms of lactose intolerance include bloating, flatulence, crampy abdominal pain, and diarrhea. They may occur within a half hour to several hours after drinking a glass of milk or ingesting a milk product.

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Treatment consists of eliminating lactose from the diet by avoiding milk and milk products and/or replacement of lactase with commercially available preparations.

SHORT BOWEL SYNDROME • Short bowel syndrome (SBS) results from extensive resection of the small intestine. o SBS is characterized by rapid intestinal transit, impaired digestive and absorption processes, and fluid and electrolyte losses. o The length and portions of small bowel resected are associated with the number and severity of symptoms. • The predominant manifestations of SBS are diarrhea, steatorrhea, and weight loss. There may be signs of malnutrition and multiple vitamin and mineral deficiencies (e.g., cobalamin and zinc deficiency, hypocalcemia). • The overall goals are that the patient with SBS will have fluid and electrolyte balance, normal nutritional status, and control of diarrhea.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

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INTESTINAL OBSTRUCTION • Intestinal obstruction occurs when a partial or complete obstruction of the intestine prevents intestinal contents from passing through the GI tract. The causes of intestinal obstruction can be classified as mechanical or nonmechanical. o Mechanical obstruction may be caused by an occlusion of the lumen of the intestinal tract. Pseudo-obstruction is an apparent mechanical obstruction of the intestine without demonstration of obstruction by radiological methods. o A nonmechanical obstruction may result from a neuromuscular or vascular disorder. •

Intestinal obstruction can be a life-threatening problem.

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Carcinoma is the most common cause of large bowel obstruction, followed by volvulus and diverticular disease. Paralytic (adynamic) ileus (lack of intestinal peristalsis) is the most common form of nonmechanical obstruction.

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Emergency surgery is performed if the bowel is strangulated, but many bowel obstructions resolve with conservative treatment.

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With a bowel obstruction, there is retention of fluid in the intestine and peritoneal cavity, which can result in a severe reduction in circulating blood volume and lead to hypotension and hypovolemic shock.

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Treatment for intestinal obstruction is directed toward 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.

POLYPS OF THE LARGE INTESTINE • The most common types of polyp are hyperplastic and adenomatous. o Hyperplastic polyps originate from the epithelium and are non-neoplastic growths. They rarely grow larger than 5 mm and never cause clinical symptoms. o Adenomatous polyps are characterized by neoplastic changes in the epithelium and are closely linked to colorectal adenocarcinoma. •

Familial adenomatous polyposis (FAP) is the most common hereditary polyp disease.

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Barium enema, sigmoidoscopy, colonoscopy and CT/MRI colonography (virtual colonoscopy) are used to diagnose polyps. All polyps are considered abnormal and should be removed.

COLORECTAL CANCER • Colorectal cancer (a malignant disease of the colon, the rectum, or both) is the second leading cause of cancer-related deaths in Canada. •

Rectal bleeding, the most common symptom of colorectal cancer, may not be visible to the naked eye. Other commonly seen manifestations include alternating Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

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constipation and diarrhea, abdominal cramps, change in stool calibre (narrow, ribbonlike), loss of appetite, early satiety, weight loss, lethargy, and sensation of incomplete evacuation. •

The digital rectal examination is the most important aspect of the physical examination because many rectal cancers are within reach of the finger. In the asymptomatic person who is 50 years or older with no risk factors (other than age), a fecal occult blood test (FOBT) or fecal immunochemical test (FIT) once a year and flexible sigmoidoscopy every 5 years beginning at age 50 are important aspects of the examination.

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Colonoscopy is the gold standard for colorectal cancer screening.

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Surgery for a colorectal cancer may include an abdominal-perineal resection. Potential complications include delayed wound healing, hemorrhage, persistent perineal sinus tracts, infections, and urinary tract and sexual dysfunctions.

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Chemotherapy is used both as an adjuvant therapy following colon resection and as primary treatment for nonresectable colorectal cancer.

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The goals for the patient with colorectal cancer include appropriate treatment, normal bowel elimination patterns, quality of life appropriate to disease progression, relief of pain, and feelings of comfort and well-being.

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Psychological support for the patient and family is important. The recovery period is long, and the cancer could return.

OSTOMY SURGERY • The creation of an ostomy is a surgical procedure in which an opening is made to allow passage of urine from the bladder, or intestinal contents from the bowel, to an incision or stoma surgically created in the wall of the abdomen. •

An ostomy is used when the normal elimination route is no longer possible.

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The two major aspects of nursing care for the patient undergoing ostomy surgery are (1) emotional support as the patient copes with a radical change in body image, and (2) patient teaching about the many aspects of stoma care and the ostomy.

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Bowel preparation may be required before surgery. Bowel preparations are used to empty the intestines before surgery to decrease the chance of a postoperative infection caused by bacteria in the feces.

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Postoperative nursing care includes assessing the stoma, protecting the skin and the stoma, selecting the pouch, providing patient education on ostomy self-care, and assisting the patient to adapt psychologically to a changed body.

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Colostomy irrigations are used to stimulate emptying of the colon in order to achieve a regular bowel pattern. If control is achieved, there should be little or no spillage between irrigations.

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The patient should be able to perform a pouch change, provide appropriate skin and stoma care, control odour, and identify signs and symptoms of complications.

ILEOSTOMY CARE • The patient with an ileostomy should be observed for signs and symptoms of fluid and electrolyte imbalance, particularly potassium, sodium, and fluid deficits. •

Pelvic surgery can disrupt nerve and vascular supply to the genitals. Radiation therapy, chemotherapy, and medications can also alter sexual function.

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Concerns of people with stomas include the ability to resume sexual activity, altering clothing styles, the effect on daily activities, sleeping while wearing a pouch, passing gas, the presence of odour, cleanliness, and decidin...