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GI Disorders

 

Ashley Ward Notes

 

Inflammatory Bowel Disease

• Is thought to be triggered by environmental agents such as pesticides, food additives, tobacco, and radiation

 

Regional Enteritis (Crohn’s Disease)

• Can occur anywhere along the GI tract, but is most common in the areas are distal ileum and colon

 

Pathophysiology

• A subacute and chronic inflammation that extends through all layers of the bowel wall from the intestinal mucosa.
• The intestinal mucosa has a cobblestone appearance, the bowel wall thickens and becomes fibrotic and the lumen narrows (advanced cases)

 

Signs & Symptoms

• Abdominal pain
• Diarrhea unrelieved by defecation
• Cramping pain after meals (the pt may tend to limit food intake, which will result in weight loss, malnutrition, and secondary anemia)
• Fever
• Leukocytosis
• Symptoms extend beyond the GI tract (arthritis, skin lesions, ocular disorders, and oral ulcers)

 

Assessment and Diagnostic Findings

• Proctosigmoidoscopic exam
• Stool exam (+occult blood and steatorrhea)
• Barium study of upper GI tract
• CBC (decreased H&H, elevated WBC)

• Albumin and protein levels may be decreased

 

Complications

• Intestinal obstruction or stricture formation
• Perianal disease
• Fluid and electrolyte imbalances
• Malnutrition from malabsorption
• Fistula and abscess formation
• High risk for colon cancer

 

Ulcerative Colitis

• Recurrent ulcerative and inflammatory disease of the mucosal layer of the colon and rectum.
• Accompanied by systemic complications and HIGH mortality rate
• High risk for colon cancer

 

Pathophysiology

• Affects the superficial mucosa of colon and characterized by multiple ulcerations, diffuse inflammations, and desquamation or shedding of colonic epithelium.
• Bleeding occurs because of ulcerations
• Begins in rectum and may involve the entire colon.
• Bowel narrows, shortens and thickens because of muscular hypertrophy and fat deposits.

 

Signs & Symptoms

• Diarrhea
• Abdominal Pain
• Intermittent tenesmus
• Rectal bleeding
• Anorexia
• Weight loss
• Fever
• Vomiting
• Dehydration
• Feeling of an urgent need to defecate
• Passage of 10-20 liquid stools a day
• Hypocalcemia and anemia
• Rebound tenderness in the right lower quadrant
• Skin lesions, eye lesions, joint abnormalities, liver disease

 

Assessment and Diagnostic Findings

• Low H&H
• Elevated WBC
• Low albumin
• Electrolyte imbalances
• Sigmoidoscopy
• Barium enemas

 

Complications

• Toxic megacolon
• Perforation
• Bleeding as a result of ulceration

• Vascular engorgement

• Highly vascular granulation tissue

*If the pt with toxic megacolon does not respond within 24-48 hrs to medical management with IV fluids, corticosteroids, and antibiotics, surgical resection is indicated.  Colonic perforation from toxic megacolon is associated with a high mortality rate.

 

MANAGEMENT OF CHRONIC INFLAMMATORY BOWEL DISORDERS

• Aimed at reducing inflammation, suppressing inappropriate immune responses, and providing rest for a diseased bowel so that healing may take place.

 

Nutritional Therapy

• Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement.
• Avoid any foods that cause diarrhea (Ex. milk)
• Avoid cold foods and smoking, these increase intestinal motility
• TPN may be needed

 

Pharmacologic Therapy

• Sedatives and antidiarrheal and antiperistaltic medications
• Sulfonamides (Azulfidine, and Gantrisin) often effective for mild to moderate inflammation
• Antibiotics used for secondary infections
• Parenteral adrenocorticotropic (ACTH) and corticosteriods are effective
• Aminosalicylates (Asacol, and Dipentum)
• Immunosuppressive agents are also used to prevent relapses.

 

Surgical Management

• Ileostomy
• Subtotal colectomy (removal of nearly all of the colon)

 

Potential complications include:            

• Electrolyte imbalances
• Cardiac dysrhythmia
• GI bleeding
• Perforation of bowel

 

NURSING INTERVENTIONS

• Ready access to a bathroom
• Bed rest to decrease peristalsis
• Anticholinergic medications administered 30 min before meals to decrease intestinal motility

• Analgesics for pain

• May have elevated urine specific gravity

• Hypotension

• Monitor glucose every 6 hr if on TPN
• Monitor rectal bleeding closely
• Monitor closely for signs of perforation (acute increase in abdominal pain, rigid abdomen, vomiting, hypotension)
• Monitor for obstruction and toxic megacolon (abdominal distention, decreased or absent bowel sounds, change in mental status, fever, tachycardia, hypotension, dehydration, and electrolyte imbalances)

 

 

Nursing Management of Pt requiring an Ileostomy

Providing Preoperative Care

• Intensive fluid, blood, and protein replacement is necessary before surgery
• Low-residue diet offered in frequent small feedings
• Usually stoma is placed in the right lower quadrant about 2 inches below the waist crease, away from scars, bony prominence, skin folds, or fistulas

 

Providing Postoperative Care

• Observe stoma for size and color (pink, bright red and shiny)
• Monitor for fecal drainage (should begin about 72 hrs after surgery)
• Accurate I&O (may be 1000-2000 mL/day)
• Sodium and potassium are depleted because of the output and may require replacements
• Nasogastric suctioning (to prevent the buildup of gastric contents)
• Nausea and distention may indicate obstruction report IMMEDIATELY

• Ambulate

 

Providing Emotional Support

• May go through various phases of grieving: shock, disbelief, denial, rejection, anger, and restitution
• Use a calm, nonjudgmental attitude
• Support groups

 

Managing Skin and Stoma Care

• Must wear a pouch at all times
• Recheck stoma 3 wks after surgery
• Use nystatin powder if irritation and yeast growth are present around stoma

 

Changing an Ileostomy Appliance

• The normal wearing time is 5-7 days before changing
• Empty every 4-6 hrs
• To reduce odors you may take bismuth subcarbonate tablets
• Lomotil a stool thickener may also assist with odor control

 

Managing Dietary and Fluid Needs

• Low-residue diet for the first 6-8 wks
• Strained fruits and vegetables are given because they are good sources of Vitamins A and C.
• Later there are few food restrictions except for food high in fiber or hard-to-digest kernels
• Gatorade is helpful in the summer to reduce fluid loss

 

 

Preventing Complications

• Common Complications include:
• Skin irritation (most common)
• Diarrhea
• Stomal stenosis
• Urinary calculi
• Cholelithiasis

 

Intestinal Obstruction

• Exists when blockage prevents the normal flow of intestinal contents through intestinal tract.
• Mechanical process- intraluminal obstruction (ex. hernias, abscesses, tumors, stenosis)
• Functional process- intestinal musculature cannot propel the contents along the bowel. (Ex. muscular dystrophy, endocrine disorders such as DM, or neurologic disorders such as Parkinson’s)
• Obstruction can be partial or complete
• MOST bowel obstructions occur in the small intestine
• The MOST common cause of small bowel obstruction are Adhesions

 

Small Bowel Obstruction

 

Pathophysiology

• Accumulation of intestinal contents, fluid, and gas develops above the intestinal obstruction.

 

Signs & Symptoms

• Crampy pain that is wavelike and colicky
• May pass blood and mucus, but no fecal matter and no flatus
• Vomiting
• Fecal vomiting takes place if the obstruction is in the ileum
• Dehydration (intense thirst, drowsiness, generalized malaise, and aching, dry MM)
• Distended abdomen

 

Assessment and Diagnostic Findings

• X-ray

 

Medical Management

• Decompression through a NG tube
• Surgery if bowel is completely obstructed and the possibility of strangulation is present.

 

Nursing Management

• Maintaining the function of NG tube
• Assessing and measuring the nasogastric output
• Assessing for fluid and electrolyte imbalances
• Assessing for improvement (return of bowel sounds, decreased abdominal distention, subjective improvement)

 

 

Large Bowel Obstruction

 

Pathophysiology

• Results in an accumulation of intestinal contents, fluid, and gas proximal to the obstruction
• Can lead to severe distention and perforation

 

Signs and Symptoms

• Symptoms develop and progress slowly
• Constipation may be the only symptom for days if in the sigmoid or rectum
• Distended abdomen

• Loops of large bowel become visibly outlined through the abdominal wall

• Crampy lower abdominal pain

• Fecal vomiting

• Symptoms of shock may occur

 

Assessment and Diagnostic Findings

• X-ray

 

Medical Management

• Colonoscopy to untwist and decompress the bowel
• Cecostomy, which is a surgical opening into the cecum.  This may be used in pts who are poor surgical risks and urgently need relief of obstruction
• Rectal tube may be used to decompress an area of the lower bowel
• Surgical resection to remove the obstructing lesion is the most commonly used procedure

 

Nursing Management

• Monitor the pts symptoms
• IV fluids and electrolytes are administered
• Prepare pt for surgery if nonsurgical treatments do not work

 

Colorectal Cancer

• Tumors of the colon an rectum
• The incidence increases with age
• Risk Factors:  family history, colon cancer or polyps, a history of inflammatory bowel disease, and a diet high in fat, protein, and low in fiber

 

 

Pathophysiology

• Predominantly adenocarcinoma (arising from the epithelial lining of intestine)
• May start as benign polyp
• Cancer cells may break away form the primary tumor and spread to other parts of the body (most often the liver)

 

Signs and Symptoms

• Determined by location, stage, and function of the intestinal segment
• MOST common is change in bowel habits
• SECOND is the passage of blood in stools
• May also include:  anemia, anorexia, weight loss, and fatigue
• Symptoms most associated with right-sided lesions are dull abdominal pain and melena.
• Symptoms most associated with left-sided lesions are the same as with obstruction (abdominal pain and cramping, narrowing stools, constipation, and distention)

• Symptoms associated with rectal lesions are ineffective, painful straining at stool, rectal pain, the feeling of incomplete evacuation after bowel movement, alternating constipation and diarrhea and bloody stools.

 

Assessment and Diagnostic Findings

• Fecal occult blood testing
• Abdominal and rectal exam
• Barium enema
• Proctosigmoidoscopy
• Colonoscopy

 

Complications

• Tumor growth may cause partial or complete bowel obstruction
• Hemorrhage
• Perforation
• Abscess formation
• Peritonitis
• Sepsis
• Shock

 

Medical Management

• IV fluids
• Nasogastric suction
• Radiation

 

Surgical Management

• Primary treatment
• May be curative or palliative
• Cancer limited to one site may be removed through the colonoscope
• Surgical procedures include: 
• Segmental resection with anastomosis (removal of the tumor and portions of the bowel on either side of the growth, as well as blood             vessels and lymphatic nodes.
• Abdominoperineal resection with permanent sigmoid colostomy (removal of the tumor and a portion of the sigmoid and all of the rectum and anal sphincter).
• Temporary colostomy followed by segmental resection and anatomosis and subsequent reanstomosis of the colostomy (allowing initial bowel decompression an bowel preparation before resection).
• Permanent colostomy or ileostomy (for palliation of unresectable obstructing lesion).

 

NURSING INTERVENTIONS

Preparing the pt for surgery

• Cleansing and sterilizing the bowel the day before the surgery
• A diet high in calories, protein and carbohydrates and low in residue is recommended for several days before surgery.
• A full liquid diet may be prescribed 24-48 hrs before surgery
• TPN may be needed
• Antibiotics such as Kantrex, Erythrocin may be administered to reduce intestinal bacteria.
• Laxatives and enemas to cleanse bowel

 

Providing Emotional Support

• Assist anxiety level
• Provide privacy
• Support groups

 

Providing Postoperative Care

• Monitor for complications such as leakage form the stoma site, prolapse of stoma, perforation, fecal impaction, and skin irritation
• Monitor for returning peristalsis

 

Providing Wound Care

• Examine dressing frequently during first 24 hrs. To detect hemorrhage
• Splint during coughing and deep breathing
• Exam stoma condition

 

Monitoring and Managing Complications

• Frequently exam abdomen including bowel sounds
• VS monitored for increasing temp, pulse, respiration’s, and decreased BP

 

Removing and Applying the Colostomy Appliance

• Will begin to function in 3-4 days after surgery
• Teach skin care

Irrigating the Colostomy

• Purpose is to empty the colon of gas, mucus, and feces

 

Supporting a Positive Body Image

• Encouraged to verbalize feelings

 

Polyps of the Colon and Rectum

• A mass of tissue that protrudes into the lumen of the bowel
• Can occur anywhere in intestinal tract and rectum
• Occur MORE commonly in the large intestine

 

Signs and Symptoms

• Depend on size and amount of pressure on intestinal tissue
• Rectal bleeding is the MOST common
• Lower abdominal pain
• Symptoms of obstruction may occur if the polyps are large enough
• Once it is discovered it is removed by colonascope

 

 

http://www.southeasternnurse.com

GI Disorders

Ashley Ward Notes

J Class of 2002 J