Assessing Clients with Bowel Elimination Disorders

Chapter 26

Review of Anatomy and Physiology

Small intestine– pyloric sphincter to ileocecal junction– three regions

duodenum jejunum ileum

– Function - chemical digestion and absorption microvilli, villi and circular folds increase surface area

Small bowel surgery

Small intestine

Review of Anatomy and Physiology

Large intestine - colon– ileocecal valve to anus– Cecum - first part of intestine - appendix– Colon divided into 3 parts

ascending transverse descending

– Function - eliminate undigestible food, absorb water, salt and vitamins

Large Intestine

Assessment of Bowel Function

Subjective– onset– characteristics– course– severity– precipitating factor– relieving factors– associated symptoms

Sample Interview Questions

Can you describe the type of cramping and abdominal pain you are having?

Have you every had bleeding from your rectum?

Have you noticed any changes in your bowel habits?

Assessing the Abdomen

Inspection, auscultation, percussion and palpation as described

Rectal exam - polyps Stool for occult blood

– + requires further testing for colon CA or GI bleeding 2nd to peptic ulcers, ulcerative colitis or diverticulosis

Blood and Stool

Melena - black tarry stool Blood on Stool - bleeding sigmoid colon, rectum Blood in Stool - colon, ulcerative colitis,

– diverticulitis, tumor, ulcer Stool black, hard = oral iron Strong odor = blood of high fat content

– steatorrhea

Nursing Care of Clients with Bowel Disorders

Chapter 26

Disorders of Intestinal Motility

Diarrhea – serious in the young and elderly– increase in the frequency, volume and fluid

content of the stool

Causes– bacteria, or parasitic infections, malaborption,

medications, diseases, allergies or pyschological

Diarrhea

Clinical Manifestations– vary widely from several large watery stool to very

frequent small stools– result in severe electrolyte imbalances

hypokalemia - Low K+ hypomagnesemia - low Mg+

– hypovolemia - fluid volume deficit - hypovolemic shock with vascular collapse

Diarrhea

Collaborative Care– treat underlying cause– Labs

stool specimen - for WBC’s, parasitic infections culture

electrolytes - imbalance

– Diagnostic tests sigmoidoscopy - direct exam of bowel

Diarrhea

Client prep– consent, npo, enemas

Dietary management– fluid replacement - gatorade, pedialyte– bowel rest for 24 hours - add milk last

Pharmacology– absorbents, anticholinergics, antibiotics

The Client with Constipation

The infrequent or difficult passage of stool– two or less BM’s per week– affects elders - impaired health, medications,

decrease physical activity

Diagnostics– Barium enema

- tumors, diverticular disease

– colonoscopy - tumor, obstruction, take bx

Constipation

Dietary Management– high fiber - vegetable fiber– adequate fluids

Pharmacology– laxatives for short term use– bulk form agents for long term use– enemas - acute short term or as prep

Irritable Bowel Syndrome

Disorder characterized by alternating periods of constipation and diarrhea

Cause - no organic cause found– related to food ingestion, meds.,

stress, hormones– looking at motor activity of the

G.I. tract

IBS

Clinical Manifestations– Colic-like abdominal pain– Altered bowel elimination

mucous in stool, change in frequency, straining, urgency, incomplete emptying

– Bloating, tenderness Labs and Diagnostics

– stool specimen, colonoscopy, UGI with SBFT Dietary management

– add fiber - adds bulk and water content

Bloating and Cramping

The Client with Fecal Incontinence

Loss of voluntary control of defecation Causes

– interfere with sensory or motor control of rectum and anal sphincters

neuro -spinal cord injury, head injury local trauma - OB tears, anal-rectal injury, surgery Other - radiation, impaction, tumors, confusion

Fecal Incontinence

Collaborative Care– dx made by history– digital exam - poor sphincter tone– treatment

bowel training program - establish regular pattern– dietary changes– stimulant - coffee, suppository, digital stimulation

surgery - colostomy

Acute Inflammatory and Infectious Disorders

Appendicitis– inflammation of the appendix– common cause of acute abd pain– most common reason for

emergency abd surgery– most common in adolescents and

young adults

Appendicitis

Simple– appendix is inflamed but intact

Gangrenous– tissue necrosis and microscopic perforations

Perforated– gross perforation and contamination of peritoneal

cavity

Appendicitis

Clinical Manifestations

– continuous mild generalized upper abd pain– then intensifies and localizes to RLQ

rebound tenderness - tenderness on release of pressure at McBurney’s point

+ Rt heel tap pain What about pain medications?

– nausea, anorexia, vomiting, low-grade fever– perforation - increased pain, temp, abscess

Appendicitis Pathophysiology

The appendix can become obstructed by fecalith (hard masses of feces) a stone, inflammation or parasites.

As a result of the obstruction the appendix becomes distended with fluid.

This increases pressure within the appendix and impairs its blood supply.

The lack of blood supply leads to inflammation, edema, ulceration, and infection of the tissue.

Can become necrotic and perforate if treatment is not indicated.

Appendicitis

Interdisciplinary Care– Labs - CBC, UA, pregnancy

test– Diagnostic studies - abd X-ray,

pelvic exam, ABD ultrasound– Pharmacology - IV’s ,

antibiotics - third generation cephalosporin - rocephin

– Surgery - Appendectomy - exploratory vs laproscopy

The Client with Peritonitis

Inflammation of the peritoneum - is the most significant complication of acute abdominal disorders– perforation of appendix, diverticulum, peptic ulcer,

pancreatitis or GSW– bacterial infection - E coli or klebsiella

Peritonitis

Clinical Manifestations– Abdominal Effects

Diffuse or localized pain - rebound Boardlike rigidity diminished or absent bs distention, anorexia, nausea, vomiting

– Systemic effects fever, malaise, tachycardia, restlessness shock

Peritonitis

Labs and Diagnostics– CBC - WBC’s with shift to the left, immature wbc

out to help fight infection– Blood culture - bacterial invasion into blood

stream– Paracentesis - obtain peritoneal fluid– Abd x-ray - free air under diaphragm indicative of

gastrointestinal perforation

Peritonitis - Interdisciplinary Care

Pharmacology– broad-spectrum antibiotics until culture report

obtained– narcotic analgesic, antipyretics

Surgery - laparotomy– peritoneal lavage

washing out cavity with copious amounts of isotonic soln drains - JP or pen rose, may be left open

Nursing Care - Peritonitis

NGT– intestinal decompression

Pain - abd distention and inflammation– assess - location, severity and type - analgesics– fowler’s - minimize stress on abd structures– alternative pain management - visualization,

medication, relaxation

Nursing Care - Peritonitis

Fluid volume deficit– I & O, vs, wt., assess for dehydration

Altered protection– monitor for sign of infection, handwashing, aseptic

technique for drsg changes

Anxiety– potential threat to life

The Client with Viral or Bacterial Infection

Gastroenteritis– describes general GI inflammation– syndrome - diarrhea, vomiting, anorexia, nausea

and pain– organisms - Staphlococcal, Salmonella,Shigella,

Botulism - life threatening, – Cholera - third world countries– dx - stool culture, tx - antibiotics, rehydration

Ulcerative Colitis– chronic inflammatory bowel disorder of the

mucosa and sub mucosa .– Affects young 15-40 yrs old– Cause

unknown, genetic component, autoimmune, dietary factors - fiber poor foods, smoking

– Affects the large bowel

Ulcerative Colitis

Clinical Manifestations– insidious onset - attack last 1 to 3 months– diarrhea - 30 to 40 stools per day with blood and

mucus– fatigue, anorexia, generalized weakness– toxic megacolon - transverse colon is paralyzed

may rupture, massive hemorrhage - need colostomy

Ulcerative Colitis

Interdisciplinary Care– supportive treatment– Dx - by sigmoidoscopy, edema, inflammation,

mucus and pus– Pharmacology

Azulfidine - sulfonamide antibiotic, acts topically on colonic mucosa to inhibit inflammatory process

– Dietary - npo with TPN, then low residue

Ulcerative Colitis

Surgery– not initial treatment– ileostomy

Nursing Care– relieving abd cramping– emotional support– teaching about illness and special needs– Nsg dx. - diarrhea and body image disturbance

The Client with Crohn’s Disease

Slowly progressive, relapsing inflammatory disorder of GI tract

diarrhea less severe, no blood or mucus

RLQ pain, fever, malaise, fatigue affect young people 10-30 can occur anywhere in the GI

tract, patchy lesions

Crohn’s Disease

Interdisciplinary Care

– therapy is directed toward managing the symptoms and controlling the disease process

Labs and Diagnostics– Stool specimen– X-ray - UGI with SBFT - shows ulcerations, strictures and

fistulas– colonosocpy - bx

Crohn’s - Interdisciplinary Care

Pharmacology– same as ulcerative colitis - anti inflammatory– antidiarrheal - no risk of mega colon

Dietary – NPO - TPN, eliminate milk

Surgery– 2nd to complications, bowel obstruction - bowel

resection

Malabsorption Syndromes

A condition in which nutrients, carbohydrates, protein, fats, water, electrolytes, minerals, and vitamins are ineffectively absorbed by the intestional mucosa– mostly disease of small intestine– surgery of small intestine

Malabsorption Syndrome

Clinical manifestations– anorexia, abd bloating, diarrhea, weight loss,

weakness, malaise, muscle cramps, anemia signs of malnutrition

Celiac Disease– hypersensitivity to gluten, protein found in cereal– Tx - gluten free diet

Malabsorption Syndrome

Lactose Intolerance– deficiency of lactase the enzymes needed for

digestion and absorbtion of lactose the primary carbohydrate in milk

– affects 90% of Asians, 75% of African Americans, high incidence among Jewish and Hispanic populations

– usually hereditary, symptoms occur in adolescence or early adulthood

Malabsorption Syndrome

Short Bowel Syndrome– from resection of significant portions of the small

intestine CA, mesenteric thrombosis with bowel infarction,

Crohn’s disease or trauma

– Treatment frequent small, high caloric and high protein meals multivitamin and mineral supplements

Neoplastic Disorders

Polyps– is a mass of tissue that arises from the bowel wall

and protrudes into the lumen– occur most often in the sigmoid colon and rectum– 30% of people over age 50 have polyps– most are benign, some have potential to become

malignant - are removed

Polyps

Interdisciplinary Care– Diagnosis made by barium enema and

sigmoidoscopy or colonoscopy– Follow-up recommended because polyps tend to

recur– Consider a “silent” disease - few or no symptoms

with significant risk of CA

The Client with Colorectal Cancer

Malignant tumor arising from the epithelial tissues of the colon or rectum

2nd leading cause of cancer death in Western countries

long term survival rate is only 35% occurs more in males than females occurs after age 50

Colorectal Cancer

Risk Factors– over age 50– polyps in colon or rectum– cancer elsewhere in the body– family history– ulcerative colitis or crohn’s disease– radiation, immunodeficiency disease– dietary - high fat, high caloric, low Ca+ and fiber

Colorectal Cancer

Clinical Manifestations– no symptoms until it becomes advanced– slow growth pattern - 5-10yrs. for symptoms to

develop– bleeding– change in bowel habit - diarrhea or constipation– pain, anorexia, weight loss - advance disease

Colon Cancer

Colorectal Cancer

Interdisciplinary Care

– establish dx - colonoscopy

– surgical intervention

– adjuncts of chemotherapy and radiation

Colorectal Cancer

Surgical resection of tumor, adjacent colon and regional lymph nodes

Dukes Staging– Stage A - confined to bowel wall– Stage B - penetration of bowel wall– Stage C - lymph node involvement– Stage D - distant metastases

Permanent for tumors of rectum or sigmoid colon

Hartmann pouch – temporary– the distal portion of the colon is left in place and

sewn shut

Double Barrel colostomy

Nursing Care of the Client Having Bowel Surgery

Pre-operative– consent– assess level of understanding– bowel prep

oral and parental antibiotics cathartics and enema to reduce risk of bowel

contamination

Nursing Care of the Client Having Bowel Surgery

Post-operative Nursing Care– Routine post-op care

vital signs, turn, cough, deep breath q2hrs I & O - NGT drainage, surgical drains assess for post-op hemorrhage

– Assess for bowel sounds and distention– Provide pain relief– Assess resp. status - teach to splint

Nursing Care of the Client Having Bowel Surgery

Post-operative care– Assess position and patency of NGT– Assess stoma - color, size, check pallor– Assess stoma out-put - usually bright red initially

then changing to clear greenish yellow by day 2-3– Encourage ambulation, this stimulates peristalsis– teach colostomy care

Nursing Care of Clients Having Bowel Surgery

Effects of ostomy on Body Image– adjust to loss of body organ and dx of cancer– show acceptance of client and ostomy– concerned over the affect of cancer– develop a trusting relationship– listen actively– ostomy, cancer support groups, social services

Colostomy Surgery

Case Study - Colorectal Cancer

W.C., 65yr old male, retired railroad employee, husband and father of 3 grown children. Has 3 month history of small amount of blood and mucus in stool. Has a sensation of rectal pressure and has notice his stool has changed in diameter, now is pencil thin.

Physician palpates a tumor in the rectum. Colonoscopy and bx confirm adenocarcinoma W.C. is scheduled for a abdonminalperitoneal

resection and sigmoid colostomy

His wife has many questions and asks, why does the colostomy have to be permanent?

Why does he need erythromycin and neomycin tablets?

She then asks, is he going to be ok?

Physician Orders

Explain the rationale behind these orders– Insert NGT and connect to low intermintent

suction– Insert foley catheter– Routine post-op v.s., OOB tonight– See PCA order sheet (M.S. 1mg q 10min, up to

10mg every 4 hours)– NPO

Nursing Interventions

Explain the rationale behind these interventions– establishing a therapeutic relationship– assessing patency and position of the NGT– assessing respiratory status– assessing b.s. – assess stoma and stoma output– teaching to splinting the incision

Structural and Obstructive Disorders

Hernia– protrusion of an organ or structure through a defect

in the muscular wall– Inguinal hernias

75% of all hernias cause by improper closure of the tract that develops as

the testes descend into the scrotum before birth bulge at inguinal cannal reducible - contents of the sac return to abd cavity strangulated hernia - blood supply is compromised

Structural and Obstructive Disorders

Umbilical hernias– occur more frequently in women– obesity, mult. pregnancies, prolonged labor– tend to enlarge steadily– strangulation is common

Incisional or Ventral hernias– occur at previous surgical incision

The Client with an Intestinal Obstruction

Occurs when intestinal contents fail to be propelled through the lumen of the bowel

Small intestine obstruction– ileum of small intestine most common site– Mechanical Obstruction

physical barrier, tumor or scar tissue

– Functional Obstruction - paralytic ileus peristalsis fails

Bowel Obstruction

The Client with an Intestinal Obstruction

Clinical Manifestations– cramping, colicky abdominal pain, can be

intermittent or increase in intensity– vomiting – high-pitched tinkling bowel sounds - reflects the

bowels attempt to propel contents past the obstruction

– later stages - absent bowel sounds– electrolyte imbalance - hypovolemia - shock

The Client with an Intestinal Obstruction

Large Bowel Obstruction– usually occurs in sigmoid colon– cancer most common cause– Clinical Manifestations

abdominal pain and constipation abdomen is distended and tender to palpation

Treatment for Bowel Obstructions– NGT - functional surgery - mechanical

Diverticulitis

The Client with Diverticular Disease

Diverticula– acquired saclike projections of mucosa through

the muscular layer of the colon– 90-95% occur in the sigmoid colon– increased incidence in US, Australia, United

Kingdom and France– related to cultural factors - diet high in refined

foods and low in fiber

The Client with Diverticular Disease

Diverticulosis– the presence of diverticula– 80% are asymptomatic

Clinical Manifestations– left-sided abd pain, constipation and diarrhea– narrow stools, occult bleeding

The Client with Diverticular Disease

Diverticulitis– inflammation and microscopic perforation of

diverticular mucosa– undigested food becomes trapped, blood flow is

impaired - leads to abscess or peritonitis Interdisciplinary Care

– Chronic diverticular disease - dietary changes– Acute diverticulosis - bowel rest, antibiotics,

eventually surgery

Anorectal Disorders

The Client with Hemorrhoids– hemorrhoidial veins become weak, distended,

develop varices - cause is straining, pregnancy also increases intra-abdominal pressure

– internal or external bleeding, bright red, unmixed with stool pain associated with thrombosed or ulcerated

The Client with Hemorrhoids

Interdisciplinary Care– conservative therapy - diet, increase fiber, fluids,

bulk forming laxative, Preparation H– surgery

sclerotherapy - inject chemical irritant to induce inflammation - fibrosis - scarring

rubber band ligation - rubber band placed snugly around - necrosis - slough

cryosurgery - necrosed by freezing with probe

The Client with Hemorrhoids

Nursing Care - post-op– inspect rectal dressing for bleeding– pain management - position of comfort - side lying– ice pack over rectal drsg– sitz bath tid and prn bowel movement– meds - analgesics, stool softeners

The Client with Anorectal Lesions

Anal Fissure– ulcers of the epithelium of the internal sphincter

Anorectal Abscess– bacteria invades pararectal space - I & D

Anorectal Fistula– tunnel or tubelike tract - leaks stool

Pilonidal Disease - chronic draining sinus