Chapter 59 - PowerPoint Presentation

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Chapter 59

Care of Patients with Noninflammatory Intestinal Disorders

Mrs. Kreisel MSN, RN

NU130 Adult Health

Summer 2011Slide2

Lower GI BleedSlide3

Irritable Bowel Syndrome (IBS)IBS is a functional GI disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating.

Manning criteria are present:Abdominal pain relieved by defecation or falling asleepAbdominal pain associated with changes in stool frequency or consistencySlide4

Irritable Bowel Syndrome (Cont’d)Abdominal distentionThe sense of incomplete evacuation of stool

The presence of mucus with stool passageA flare-up of symptoms usually brings the patient to the health care provider.Slide5

Treatment Health teaching—t

eaching the patient to avoid problem stimulantsDiet therapy—eliminating offending or upsetting foodsDrug therapy—bulk-forming laxatives, antidiarrheal

agents, 5-HT4

antagonists, M3-receptor antagonists, and

tricyclic

antidepressants

Stress management based on the patient’s current and ongoing stressors

Complementary and alternative therapies used to reduce symptoms and discomfortSlide6

Herniation Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes

Types of hernia include:Indirect inguinal Direct inguinal Femoral Umbilical Incisional or ventral Slide7

Common Abdominal HerniasSlide8

Classification of HerniasReducible: When the contents of the

hernial sac can be placed back into the abdominal cavity by pressure.Irreducible: Also know as incarcerated hernia, cannot be reduced or placed back into the abdominal cavity. Requires emregency surgical evaluation.

Strangulated:

When the blood supply to the herniated segment of the bowel is cut off by pressure from the

hernial

ring (the band of muscle around the hernia).

WHAT NURSING CONSIDERATIONS ARE IMPORTANT FOR THIS TYPE OF HERNIA?Slide9

Nonsurgical ManagementTruss: For people not able to undergo surgery and is mainly for males.

It is a pad made with firm material and is held inplace over the hernia with a belt to keep the abdominal contents from protruding into the hernia sac. The surgeon must reduce the hernia if it is not incarcerated. The patient applies it in the morning.Lots of Nursing Education is the prioritySlide10

Surgical Management Preoperative care—NPO day of surgery

Operative procedures:Minimally invasive inguinal hernia repair (MIIHR) (herniorrhaphy)HernioplastyOpen or conventional herniorrhaphySlide11

Postoperative CareAfter open surgical approach, have patient avoid coughing.After indirect inguinal hernia repair, a scrotal support and use of ice bags to the scrotum may be used to prevent swelling. Elevation of the scrotum on a soft pillow helps prevent and control swelling.

Difficulty voiding.Slide12

Colorectal Cancer (CRC)Colorectal refers to the colon and the rectum, which together make up the large intestine.

Most CRCs are adenocarcinomas.Etiology:Age older than 50 yearsGenetic predispositionPersonal or family history of cancer

Familial

(disease that occurs more in a family then would be expected by chance)

adenomatous

(glandular tissue over growths)

polyposis

(the presence of numerous polyps)Slide13

Colorectal Cancer (Cont’d)Slide14

Health Promotion and MaintenanceGenetic testing for FAP (familial

adenomatous polyposis)and HNPCC (herediary nonpolyposis colorectal cancer)Diet modification

Colon cancer screening

Aspirin therapy

Dietary calcium supplementsSlide15

Clinical Manifestations Most common signs—

rectal bleeding, anemia, and a change in the stool.The clinical manifestations of colon rectal cancer depend on the location of the tumor.Slide16

Laboratory AssessmentHemoglobin and hematocrit values usually decreasedFecal occult blood test

Possible elevation of carcinoembryonic antigenImaging assessmentOther diagnostic testsGenetic counselingSlide17

Nonsurgical ManagementAmerican Joint Committee on Cancer Stage I

—tumor invades up to muscle layerStage II—tumor invades up to other organs or perforates peritoneumStage III—any level of tumor invasion and up to 4 regional lymph nodes

Stage IV

—

any level of tumor invasion; many lymph nodes affected with distant metastasisSlide18

Nonsurgical Management (Cont’d)Radiation therapyDrug therapySlide19

Surgical Management Colon resection

ColectomyAbdominoperineal (AP) resection ColostomyMinimally invasive surgerySlide20

Surgical Management (Cont’d)Preoperative care includes:

Consultation with enterostomal therapistDiscussions with surgeon of risk for sexual and urinary dysfunctionsBowel prepNasogastric tube and IV line placed for use after surgeryAssignment of case manager for long-term consequencesSlide21

Colostomies Slide22

Surgical ManagementOperative proceduresPostoperative careSlide23

Nursing Interventions:PRIMARY:

Assess the meaning and effect of cancer as perceived by the client!Colostomy CareNormal appearance of the stoma

Signs and symptoms of complications

Measurement of the stoma

Choice, use, care, and application of appropriate appliance to cover stoma

Measures to protect the skin

Dietary measures to control gas and odor

Resumption of normal activitiesSlide24

Intestinal Obstruction Mechanical obstruction

Nonmechanical obstruction, also known as paralytic ileus or adynamic ileusStrangulated obstruction resulting from tumors, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis, vascular disorder, and adhesionsSlide25

Mechanical ObstructionSlide26

Clinical Manifestations of Mechanical ObstructionMidabdominal pain or cramping

VomitingObstipation (extreme constipation)DiarrheaAlteration in bowel pattern and stoolAbdominal distention

Absence of

Borborygmi

(a gurgling, splashing sound normally heard over the large intestine; caused by gas passing through the liquid contents of the intestine)

Abdominal tendernessSlide27

Clinical Manifestations of Nonmechanical ObstructionConstant, diffuse discomfort

Abdominal distentionDecreased to absent bowel soundsVomitingObstipation Slide28

Assessment Laboratory assessment

Imaging assessmentOther diagnostic testsSlide29

Nonsurgical ManagementNothing by mouthNasogastric tube placement

Nasointestinal tubesIV fluid replacement and maintenanceMouth carePain managementDrug therapySlide30

Surgical ManagementExploratory laparotomyPreoperative care

Operative procedurePostoperative careSlide31

Abdominal TraumaInjury to the structures located between the diaphragm and the pelvis, which occurs when the abdomen is subjected to blunt or penetrating forces

Organs may include the large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary bladderBlunt abdominal trauma, which often occurs in motor vehicle accidentsPenetrating abdominal trauma caused by gunshot wounds, stabbingSlide32

Assessment

Assess airway, breathing, and circulationAssess for:Hypovolemic shockCullen’s sign: bluish discoloration of the periumbilical

skin due to

intraperitoneal

hemorrhage.

Turner’s

sign:

: bluish discoloration on the flank may indicate retroperitoneal bleeding into the abdominal wall

Ballance’s

sign: pt on Left side and do percussion. Left flank dullness and resonance over the right flank

Kehr’s

sign: Left shoulder pain resulting from diaphragmatic irritation as seen in spleen injury.

Dullness over hollow organs like the stomach or intestines may mean blood or fluid in that area.Slide33

Abdominal Trauma: Emergency CareTwo large-bore IV lines are placed

Central venous catheterType and crossmatch 4 to 8 units of bloodBalanced saline solution, crystalloids, and possibly bloodArterial blood gas assessmentFluid and electrolyte managementContinuous hemodynamic monitoring

Surgical managementSlide34

Polyps Small growths in the intestinal tract that are covered with mucosa and are attached to the surface of the intestine

Various typesFamilial adenomatous polyposisUsually asymptomatic, but can cause gross rectal bleeding, intestinal obstruction, and intussusceptionNursing care Slide35

Polyps (Cont’d)Slide36

Hemorrhoids Unnaturally swollen or distended veins in the anorectal region

Internal hemorrhoidsExternal hemorrhoids Nonsurgical managementSurgical management—hemorrhoidectomySlide37

Malabsorption Syndrome Syndrome associated with a variety of disorders and intestinal surgical procedures

Primary clinical manifestations—diarrhea and steatorrheaInterventions:Dietary managementSurgical or nonsurgical managementDrug therapySlide38

NCLEX TIMESlide39

Question 1How many Americans are estimated to suffer from

irritable bowel syndrome? 7% to 12%

10% to 22%

25% to 33%

35% to 40%Slide40

Question 2What symptom does the nurse expect the patient with intussusception to exhibit?

Decrease in pulse Extremely elevated body temperature

Singultus (hiccups)

Frequent bloody stoolsSlide41

Question 3

What is a priority nursing intervention in the care of a patient with chronic diarrhea?

Keep the skin clean and dry.

Use medicated wipes rather than washcloths to clean the perineal area.

Consult a nutritionist for suggested fibers to add to the diet.

Review the patient’s medications that may be exacerbating the diarrhea.Slide42

Question 4A 21-year-old female college student presents to the clinic complaining of lower abdominal pain, constipation and diarrhea, and belching and bloating sensation. The most likely cause of her symptoms is:

Appendicitis Diverticular disease

Irritable bowel syndrome

Mental health disorderSlide43

Question 5What percentage of people develop polyps or colorectal tumor by age 70 years?

10% 25%

40%

50%