Assessing Clients with Bowel Elimination Disorders

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Assessing Clients with Bowel Elimination Disorders

• Chapter 26

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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

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Small bowel surgery
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Small intestine
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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

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Large Intestine
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Assessment of Bowel Function

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

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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?

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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

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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

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Nursing Care of Clients with Bowel Disorders

• Chapter 26

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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

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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

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Diarrhea

• Collaborative Care
• treat underlying cause
• Labs
• stool specimen - for WBCs, parasitic infections
  culture
• electrolytes - imbalance
• Diagnostic tests
• sigmoidoscopy - direct exam of bowel

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Diarrhea

• Client prep
• consent, npo, enemas
• Dietary management
• fluid replacement - gatorade, pedialyte
• bowel rest for 24 hours - add milk last
• Pharmacology
• absorbents, anticholinergics, antibiotics

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The Client with Constipation

• The infrequent or difficult passage of stool
• two or less BMs per week
• affects elders - impaired health, medications,
  decrease physical activity
• Diagnostics
• Barium enema
• - tumors, diverticular disease
• colonoscopy
• - tumor, obstruction, take bx

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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

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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

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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

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Bloating and Cramping
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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

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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

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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

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Appendicitis

• Simple
• appendix is inflamed but intact
• Gangrenous
• tissue necrosis and microscopic perforations
• Perforated
• gross perforation and contamination of peritoneal
  cavity

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Appendicitis

• Clinical Manifestations
• continuous mild generalized upper abd pain
• then intensifies and localizes to RLQ
• rebound tenderness - tenderness on release of
  pressure at McBurneys point
• Rt heel tap pain
• What about pain medications?
• nausea, anorexia, vomiting, low-grade fever
• perforation - increased pain, temp, abscess

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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.

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Appendicitis

• Interdisciplinary Care
• Labs - CBC, UA, pregnancy test
• Diagnostic studies - abd X-ray, pelvic exam, ABD
  ultrasound
• Pharmacology - IVs , antibiotics - third
  generation cephalosporin - rocephin
• Surgery - Appendectomy - exploratory vs laproscopy

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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

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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

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Peritonitis

• Labs and Diagnostics
• CBC - WBCs 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

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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

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Nursing Care - Peritonitis

• NGT
• intestinal decompression
• Pain - abd distention and inflammation
• assess - location, severity and type - analgesics
• fowlers - minimize stress on abd structures
• alternative pain management - visualization,
  medication, relaxation

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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

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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

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• 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

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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

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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

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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

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The Client with Crohns 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

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Crohns 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

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Crohns - 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

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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

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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

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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

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Malabsorption Syndrome

• Short Bowel Syndrome
• from resection of significant portions of the
  small intestine
• CA, mesenteric thrombosis with bowel infarction,
  Crohns disease or trauma
• Treatment
• frequent small, high caloric and high protein
  meals
• multivitamin and mineral supplements

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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

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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

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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

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Colorectal Cancer

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

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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

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Colon Cancer
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Colorectal Cancer

• Interdisciplinary Care
• establish dx - colonoscopy
• surgical intervention
• adjuncts of chemotherapy and radiation

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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

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• Permanent for tumors of rectum or sigmoid colon
• Hartmann pouch temporary
• the distal portion of the colon is left in place
  and sewn shut

Permanent f
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Double Barrel colostomy
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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

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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

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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

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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

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Colostomy Surgery
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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.

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

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• 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?

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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

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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

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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

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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

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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

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Bowel Obstruction
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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

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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

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Diverticulitis
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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

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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

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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

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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

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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

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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

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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