NURSING II Kathleen C. Ashton

1
NURSING IIKathleen C. Ashton

• The Client With Alterations
• in Bowel Elimination

2
Assessment

• Careful H P
• History family history of weight gain or loss,
  gi conditions
• Patterns eating, foods, bowel habits - any
  change, laxative use, pain
• Screening last exam

3
Constipation

• Start with what is normal for client (3x/day to
  3x/week)
• Characterized by abnormal hardening and
  infrequency of defecation
• Causes reduced fiber bulk in diet hurried,
  stressful, sedentary lifestyle laxative abuse
  disease conditions cancer, obstruction,
  diverticulitis, DM, MS, hypothyroidism,
  pheochromocytoma, hemorrhoids drugs
  tranquilizers, anticholinergics, antacids
  containing aluminum lupus, emphysema.
• Laxatives given with appendicitis can lead to
  rupture

4
Gerontologic Considerations

• Increased complaints - may be related to reduced
  bulk, ill-fitting dentures, reduced fluids,
  reduced activity. Some become bowel conscious.
  Teach what is normal.
• Goal determine normal pattern simulate it with
  natural means. Treat the cause.
• Interventions Add 6-12 tsp. bran to diet daily.
  Increase fluids. Increase activity, set regular
  time for defecation. Reduce anxiety. Avoid
  valsalva maneuver.

5
Diarrhea

• More than 3 bowel movements/day, increasing
  liquid stools.
• Small volume ulcerative colitis, Crohns disease
  (Know these conditions)
• Infectious from food source or within intestines
• Prevention proper food handling, cleaning of
  kitchen utensils, attention to diet, stress
  reduction, standard precautions, prevent spread
  of infectious diarrhea

6
Infectious Diarrhea

• SS gray-brown liquid stool, foul smell,
  borborygmous, anorexia, thirst, tenesmus. May
  lead to dysentery.
• Lab values CBC with differential shows
• High neutrophils (infection)
• High eosinophils (parasitic infestations)
• Proctoscopy barium enema may be ordered

7
Management

• May need IVs - especially children elderly
• Prednisone may decrease inflammation
• Lomotil, Donnegel, Immodium to reduce motility
• Keflex for infections
• Replace K fluids (Gatorade or Pedialyte)
• Keep anal area clean and dry
• Provide access to bathroom
• BRAT Diet Bananas, Rice, Applesauce, Toast/Tea

8
Intestinal Obstruction

• Partial or total impairment of forward flow of
  intestinal contents. Two types
• mechanical from tumors, adhesions,
  intussusception, abcesses
• paralytic decreased peristalsis from DM,
  surgery, muscular dystrophy or neurologic disease
• 60 of obstructions caused by adhesions

9
Signs and Symptoms

• Pain as intestine tries to break up obstruction.
• Borborygmous, then emesis as waves propel
  contents backward. Contents appear more fecal,
  the lower the obstruction. High obstruction
  results in oliguria from fluid loss.
• Abdominal distention - more diffuse with lower
  obstructions.
• Colon may continue to empty - may have bowel
  movements.

10
Management

• May attempt to dislodge obstruction or decompress
  the bowel with weighted intestinal tube (Cantor,
  Miller-Abbott, Harris)
• Surgery to relieve mechanical obstructions caused
  by adhesions and hernias
• Fluid replacement and analgesics given
• Saline used to ensure patency of tube
• Position changes helpful in advancing intestinal
  tubes
• Skin integrity a concern

11
Inflammatory Bowel Disease

• Crohns Disease- Chronic inflammation anywhere in
  the GI tract, usually in ileum
• Common in Jewish people runs in families
• SS Chronic diarrhea, crampy abdominal pain,
  fever, weight loss and anorexia. May develop
  bowel obstruction and fistula.
• No known cure
• Treatment TPN, bowel resection
• Immuran, asulfadine, sulfasalizine given
• Ulcerative colitis - only in colon colostomy is
  curative. Antibiotics used only with Crohns

12
Vascular Occlusions

• Lack of blood flow may predispose to necrosis and
  perforation of abdominal viscera
• Causes trauma, emboli, hypovolemia, spasm,
  iatrogenesis, thrombi of major vessels. Common in
  elderly. Results in bowel infarction.
• SS Vague at first - may be missed.
  Leukocytosis, left lower quadrant pain,
  distention, NV, shock, fluid electrolyte
  imbalance.
• Surgery may be indicated with end-to-end
  anastamosis or temporary ostomy to allow healing

13
Abdominal Wall Hernia

• Protrusion of abdominal cavity contents through a
  congenital, acquired, or post-op defect in
  abdominal muscle wall
• Sites inguinal, umbilical, femoral, spigelian
• Worsened by coughing, straining, lifting
  incorrectly. Progressive enlargement
• Inguinal hernias occur 3x more often in men
  more common in elderly - intestines protrude into
  groin or scrotum. Pain frequency common
• Umbilical hernias occur more frequently in women
  - associated with pregnancy and obesity

14
Management

• Reducible hernias can be replaced in abdomen
• Obstruction or incarceration pain swelling
• Strangulated hernias require extensive surgery -
  may be as an outpatient if a simple repair. May
  experience prolonged scrotal swelling, wound
  infection, urinary retention mild paralytic
  ileus
• Good history is vital - include pain history -
  small hernias can be very painful
• Truss may be used for support - fitted by
  knowledgeable person, keep underlying skin clean
  dry, prevent irritation
• Avoid prolonged standing, straining or lifting

15
Tumors and Intestinal Cancer

• Colorectal cancer seen in all age groups -
  highest incidence in ages 60 older. Second only
  to lung cancer. 50 cure rate, if recurs, only 5
  cure rate.
• Risk factors family history of cancer or
  irritable bowel disease, pelvic irradiation, over
  age 40, urban living, colitis.
• Early screening could help save more lives
• Associated with history of rectal polyps diet
  high in fat, protein, beef, low in fiber

16
Diagnosis

• Stool hematest done by many hospitals now as a
  community service
• Rectal bleeding most common sign - dark to bright
  red depending on site
• Barium enema, or lower gi series
• Proctosigmoidoscopy, colonoscopy. Sigmoidoscopy
  recommended every 2 years for those over age 50
• Carcinoembryonic antigen (CEA) levels used to
  provide prognosis - not reliable for diagnosis,
  many false negatives

17
Management

• Surgery usually indicated.
• Location and size of tumor determines extent of
  surgery. Usually need to take extra surrounding
  tissue to get it all.
• Irradiation produces severe gi symptoms - used
  only with limited disease, frequently used with
  rectal If encapsulated, some cancerous tumors can
  be removed via colonoscope.

18
Procedures

• Hemicolectomy - removal of tumor plus surrounding
  colonic tissue with anastamosis of the colon
• Temporary colostomy - stoma created to allow
  healing with intent to reconnect at a later date
  (usually 6-8 weeks) - frequently a double barrel
• Permanent colostomy - created when insufficient
  tissue remains for anatomosis - frequently a
  single barrel. Used with rectal cancer - no
  tissue to anastamose

19
Types of Colostomies

• Transverse high with semifluid feces
• Descending or sigmoid more solid feces
• Ascending rare, fluid stool
• Double barrel
• upper stoma stool
• lower stoma mucous fistula
• Kochs pouch continent ileostomy

20
Non surgical means

• Becoming more popular
• Irradiation may be used prior to surgery to
  reduce tumor size and prevent cell implantation
  during resection. May be used for palliation in
  inoperable tumors
• Intracavity and implantable radiation devices
  used. Caution about radioactivity
• Chemotherapy may be used with surgery
• 5FU - potentiated by folinic acid
• mitomycin IV

21
Other treatments

• Immunotherapy is experimental
• Macrobiotic diets and imagery tried - picture T4
  cells waging war against the cancer cells
• Laughter and other therapies gaining popularity

22
Complications

• Surgical asepsis is very important
• Prolapse of stoma may occur - usually related to
  obesity
• Wound infection with hemicolectomy - dehiscence
  or evisceration
• Obstruction and other problems with function

23
Nursing Implications

• Support is essential - grief from
• loss of function
• loss of social role
• loss of life (poor prognosis with advanced
  disease)
• Understanding of treatments and prognosis
  important for compliance
• Pre op teaching should include discussion of
  ostomy. May mark site of ostomy
• Nutrition assessment
• Nurture a sense of hope
• Home care referral to wound care specialist

24
Management

• ET nurse for support
• Irrigations no longer used. Some dont need
  pouch, especially with sigmoid.
• Some stomas adjacent to surgical wound - problems
  with infection, healing, wearing an appliance
• Stomahesive, Karaya powder or paste used to
  prevent skin irritation.
• Many new products available, but insurance
  company may dictate what can be used.