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Medical Surgical Nursing

Chapter 52
Caring for Clients With Disorders of the Lower GI Tract
Altered Bowel Elimination
 Constipation
 everyone has different bowel habits, frequency of stool.
 What is normal for that client?
 If constipated for a long period may develop encopresis, passing liquid stool
around an obstructive stool mass
 Box 52-1, dietary modifications for diarrhea or constipation
 Drug therapy table 52-1
 Diarrhea
 passage of frequent liquid or semiliquid stools
 S/S: urgency, cramps, hyperactive bowel sounds
 Treatment: dietary rest for 1-2 meals , antidiarrheal agents, IV replacement of
fluids & electrolytes, TPN
 See nursing process

Irritable Bowel Syndrome


 Also called spastic colon, IBS is a cluster of S/S
 Cause: unknown
 Experience fluctuations between diarrhea & constipation. May get worse with
stress
 Treatment: trial & error dietary elimination of foods that cause problems, high
fiber diet to prevent constipation and/or drugs for diarrhea
 See fig 52-1
Inflammatory Bowel Disease – table 52-1
 Crohn’s Disease or regional enteritis
 Usually occurs in young adulthood
 Chronic disease
 Cause:unknown
 S/S: pain, abdominal distention, poor nutritional status
 Treatment: supportive
 Ulcerative Colitis
 occurs in young & middle aged adults
 Prolonged remission possible
 Cause: unknown
 Onset abrupt
 S/S: cramps, diarrhea, incontinence
 Treatment: achieve & maintain remission
 see client & family teaching 52-1
Acute Abd Inflammatory Disorders
 Appendicitis
 More common in adolescents & young adults
 S/S:similar to many other disorders; abd pain, localized to RLQ of abdomen at
McBurney’s point, rebound tenderness, fever, n/v
 Box 52-2 – precautions when assessing a client for appendicitis
 Treatments: antibiotics, npo, temporarily withhold analgesics until decision is
made whether or not to do an appendectomy
 Nursing care: v/s, pain meds, assessment of return of bowel sounds, early
ambulation
Peritonitis
 Inflammation of the peritoneum caused by perforation of a peptic ulcer, bowel or
appendix, etc & spillage of chemical contents and/or bacteria into the peritoneum

 S/S: severe abd pain with tenderness, distention, n/v. Lack of bowel motility, abd
becomes rigid
 Treatment: ngt for decompression, IV fluids, large doses of antibiotics & pain
meds
 Requires surgical repair
Intestinal Obstructions
Nonmechanical-adynamic or paralytic ileus such as after surgery, inflammatory
conditions, electrolyte disturbances
 S/S: n/v, distention, slow or absent bowel sounds
 Mechanical-lumen is blocked by tumors, adhesions, etc- table 52-2
 S/S: may have hyperactive bowel sounds above the area of obstruction
Treatment for Obstructions
 Medical:
 NPO
 IV fluids
 intestinal decompression via abdominal tube
 See nursing guidelines 52-1
 Nursing:
 I&O
 V/S
 documentation of emesis, bowel sounds, pain management
 Maintenance of the decompression tubes
Diverticular Disorders
 Diverticula-sacs or pouches of mucosa of the intestine that protrude through
lining of the intestine
 See fig 52-5
 If they are asymptomatic they are called diverticulosis
 Diverticulitis is an inflammed diverticula
 Cause unknown
 More common in countries with low fiber diets
 S/S: constipation alternating with diarrhea, gas, pain, tenderness, fever, rectal
bleeding
DIVERTICULAR DISORDERS
 No treatment if asymptomatic, avoid constipation & foods containing seeds that
could get caught in the pouches. May require removal of that portion of the intestine
 Nursing care: follow MD recommended diet, increase bran to add bulk to diet,
avoid use of laxatives or enemas, avoid constipation, do not suppress the urge to defecate,
drink at least 8-10 glasses of fluid daily, exercise
Abdominal Hernias
 Protrusion of intestine through the abdominal wall – box 52-3
 Incisional-previous scar
 Inguinal-along the inguinal canal
 Umbilical-protruding umbilicus
 Femoral-higher incidence of strangulation
 Causes: straining increases intraabd pressure, obesity, congenital weakness in the
abd wall
 Treatment: depends on whether symptomatic or not; may wait & see if symptoms
develop & do surgical repair
Abdominal Hernias
 Nursing care:
 Teaching if supportive care prescribed, s/s of incarcerated or strangulated hernia
to report to MD
 Post op care: v/s, home care teaching, avoid constipation & straining at stool,
avoid heavy lifting
Cancer of the Colon And Rectum
 2nd leading cause of cancer deaths in the US
 Risks increase with age
 American Cancer society recommends annual fecal occult blood testing &
colonoscopy every 10 yrs after age 50
 Strong genetic component
 Cancerous lesion develops from benign due to genetic, environmental & lifestyle
factors
Cancer of the Colon And Rectum
 S/S: change in bowel habits, occult or frank blood in stool, dull, vague abdominal
discomfort. Pain is late sign of cancer
 Med surg treatment: polyps removed during endoscopic exam, if benign f/u
recommended; if cancerous surgery is done with radiation & chemotherapy
 Nursing mgmt: preparation for routin colorectal screening – box 52-5; see post op
care ch 54
HEMORRHOIDS
 Dilated veins outside or inside the anal spincter, fig 52-7
 Caused by: chronic straining with BM, prolonged sitting, pregnancy, prolonged
labor, portal HTN
 External: may be asymptomatic or cause itching, pain, soreness
 Internal: bleeding
 Medical mgmt: symptomatic with meds or hemorrhoidectomy sometimes done
PILONIDAL SINUS
 Infection in the hair follicles in the sacrococcygeal area above the anus, fig 52-9
 Seen mostly in people with deep intergluteal cleft & abundant hair in the perianal
& lower back regions
 S/S: pain & swelling at base of spine & purulent drainage
 Medical/surgical mgmt: I&D done, packed & heals by secondary intention
General Nutritional Considerations
 In order to get a enough fiber in diet: 6-11 servings of breads, cereals, & grains to
include high fiber bread & cereal
 Encourage clients to eat:
 ½ cup of dried peas or beans daily
 2-4 servings of fruit daily with skin & seeds
 3-5 servings of vegetables
 For clients with diverticulosis they cannot eat foods with husks & seeds (nuts,
popcorn, cucumbers, etc) which will become trapped in the diverticula

General Pharmacologic Considerations


 Narcotics & sedatives can decrease peristalsis & cause constipation
 Habitual use of laxatives can decrease muscle tone of the intestine & result in
constipation
 The misconception that a daily BM is necessary may contribute to laxative
overuse. Teach the client about normal bowel patterns, which may vary from 1-3 stools
per day to 1 bowel movement every 3 days
General Gerontologic Considerations
 Constipation is a common problem in older adults & often results from inadequate
fluid intake, dietary fiber & lack of exercise
 An older adult with prolonged constipation that shifts to diarrhea should be
checked for fecal impaction
 Older adults may not display the usual signs of severe pain that younger adults
with appendicitis may display, leading to delayed diagnosis of acute appendicitis.

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