AssessmentAndManagementOfPatientsWithLowerGI [EDocFind.com]

8/7/2019 AssessmentAndManagementOfPatientsWithLowerGI [EDocFind.com]

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Assessment And Management OfPatients With Lower GI TractDisorders

NUR 111Common Health Problems


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Anatomy and Function of Lower GI Tract

GI Tract = 23- 26 feet long: extends from mouththrough esophagus, stomach, and intestines to theanus

Small Intestine Function:Small Intestine Function:

Longest segment of GI tract, absorption of

nutrients into bloodstream through intestinal walls 3 anatomic parts: duodenum, jejunum, ileum

Digestive enzymes and bile in the duodenumcome from pancreas, liver, gallbladder and glands

within the intestines Intestinal glands secrete mucus, hormones,

electrolytes and enzymes


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Ileal Villi


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2 types of contractions: Small Intestine

Segmentation contractions:

Intestinal peristalsis:

Colonic Function: (Ascending, Transverse,Descending, Sigmoid, and Rectum)

Within 4 hrs of eating residual wastematerial passes through ileocecal valveinto colon

Bacteria make up a major part of thecontents of large intestine

2 types of secretions: bicarbonate(neutralize) and mucus (protects colonicmucosa)


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Ileocecal Valve


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Colonic Function, Cont.

Slow, weak peristaltic activity movescolonic contents along tract, allowing

efficient reabsorption of H2O andelectrolytes

Fecal material is approx. 75% fluid,

25% solid, brown in color frombreakdown of bile, odor comes frombacteria byproduct


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Health Hx. And Clinical

Manifestations

Tobacco and alcohol

Medications

Surgeries Unexplained Wt. Gain or Loss

Pain (location, duration, frequency etc.)

Indigestion

Intestinal Gas

Nausea and Vomiting

Changes in Bowel Habits and Stool


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Physical Assessment & Diagnostic Evaluation

Assessment: mouth, abdomen, rectum

Mouth: teeth, gums, tongue

Abdomen: look, listen, then feel

Anal and perineal area

Diagnostic Evaluation

Blood work: CBC, liver panel

Stool test: occult blood, parasites, etc.

Hematest: most common for occultblood


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Lower GI tract studies: Barium Enema: detect polyps, tumors,

lesions of colon Radiopaque substance instilled rectally Gastrografin (water-soluble iodine

contrast) used in inflammatory diseaseor perforated colon

Nursing Interventions: May vary accordingto MD orders, condition of client etc.

Computed Tomography: cross-sectionalimages Nursing Interventions: NPO for 6-8 hrs

prior, assess for allergies to contrast dye


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Magnetic Resonance Imaging: Noninvasive,uses magnetic fields and radio waves:

Useful in evaluating soft tissues, vessels

Nursing Interventions: NPO for 6-8 hrs

prior, remove all jewelry, procedure takes30-90 minutes, close fitting scanner maycause feelings of claustrophobia

Anoscopy, Proctoscopy, Sigmoidoscopy:

Nursing Interventions: Minimal bowelcleansing, monitor vital signs during andafter procedure


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Colonoscopy: Direct visual inspection of colon tocecum

Flexible fiberoptic colonoscope, can obtainbiopsies and remove polyps

Usually takes one hour, pt on left side, legs drawn

toward chest Nursing Interventions: May vary according to MD

orders

Bowel cleansing (Colyte, Golytely) clear liquids daybefore, Informed consent, NPO night before, IV

midazolam (Versed) for sedation. During procedure monitor vital signs, O2

saturation, color and temp of skin, level ofconsciousness, vagal response


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Colonoscopy


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Gerontologic Considerations

Oral Cavity

Tooth loss or decay Atrophy of taste buds

Esophagus

Weakened gag reflex

Stomach Decrease gastric secretions

Decrease motility

Small Intestine

Atrophy of muscle and mucosal surfaces Large Intestine

Decrease mucus production

Decrease tone of anal sphincter


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Abnormalities of Fecal Elimination

Constipation: irregular, hard stool: may be caused

by certain meds, hemorrhoids, obstructions,neuromuscular diseases Complications: Hypertension, fecal impaction, hemorrhoids,

megacolon

Nursing Management: increase fiber, fluids, laxatives as ordered

Diarrhea: Increase in frequency, amount andaltered consistency (looseness): Irritable Bowel

Syndrome (IBS), Inflammatory Bowel Disease (IBD),and lactose intolerance are frequently underlyingdisease processes Acute or Chronic

Complications: dehydration, cardiac dysrhythmias (low potassium)always be aware of Potassium levels

Nursing Management: Stool specimen, bed rest, low bulk diet inacute phase, advance to bland diet, no caffeine, carbonated drinks,antidiarrheal meds as ordered, diphenoxylate (Lomotil), loperamide(Imodium)


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Irritable Bowel Syndrome (IBS)

Common GI problem, cause unknown, certain factors

associated with syndrome: heredity, depression,anxiety, high fat diet, smoking, alcohol

Results from functional disorder of intestinal motility

Clinical manifestations: constipation, diarrhea, orboth, pain, bloating

Assessment and diagnostic findings: diagnosis madewhen tests rule out structural or other colon disease

Medical management: Treatment aimed at relievingpain, constipation and diarrhea, reducing anxiety and

stress

Nursing Management: patient education, reinforcegood diet, not smoking and no alcohol


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Zelnorm


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Acute Inflammatory Intestinal Disorders

Appendicitis: most common reason forabdominal surgery, appendix becomesinflamed from obstruction, may become pusfilled

Clinical manifestations: Right lowerquadrant pain, low grade temp, N/V,rebound tenderness, rupture causes diffusepain and condition worsens

Assessment and Diagnostic: CBC, CT of

abdomen, Ultrasound


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Opening of Appendix


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Appendicitis


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Appendicitis

Complications: Perforation leading toperitonitis or abscess

Medical Management: Surgery as soon aspossible, IV fluids and antibiotics,analgesics, Appendectomy may beperformed with low abdominal incision orby laparoscopy

Nursing Management: Goals include,relieving pain, preventing fluid and

electrolyte imbalance, dehydration, andinfection

Surgery may be outpatient, if complications ofperitonitis are suspected pt may remain in hospital

for several days


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Acute Inflammatory Intestinal Disorders

Diverticulitis: Diverticulum is saclikepouching of lining of bowel extendingthrough defect in muscle. Most commonin sigmoid colon

Clinical Manifestations: Chronicconstipation, intervals of diarrhea, leftlower quadrant pain, anorexia, fatigue

Assessment and Diagnostic: CT scan

procedure of choice, CBC


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Diverticula Diverticula seen on

colonoscopy


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Diverticula Diverticula seen on

barium enema


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Diverticulitis Complications: peritonitis, abscess formation,

bleeding

Medical Management: Usually treatedoutpatient with diet and medicine therapy,antispasmodics, antibiotics, bulk laxative,clear liquids until inflammation resolved then

high fiber, low fat Acute case may require hospitalization,

especially for elderly andimmunocompromised

Surgery may be necessary with abscess formation orperforation

Nursing Process: encourage high fiber diet, exercise,bulk laxatives


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Peritonitis

Inflammation of the peritoneum, the serous

membrane lining the abdominal cavity and coveringthe organs.

Clinical Manifestations: Affected area of abdomenbecomes tender, distended, rigid. Reboundtenderness, paralytic ileus, N/V

Assessment and Diagnostic: CBC, Abdominal CT scanor X-ray, peritoneal aspiration and culture of fluid

Complications: Generalized sepsis (major cause ofdeath), inflammation may cause bowel obstruction

Medical Management: Fluid & electrolyte

replacement, analgesics, antiemetics, NG suction,massive antibiotics, surgery to remove infectedmaterial

Nursing Management: Ongoing assessment of vitalsigns, pain, GI function, intake and output


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Inflammatory Bowel Disease (IBD)

Refers to 2 chronic inflammatory GI

disorders: regional enteritis (Crohnsdisease) and ulcerative colitis. Both havesimilarities but are ultimately different.

Cause of IBD is unknown. Occurs equally inwomen and men.

Believed to be triggered by environmentalagents such as food additives, tobacco, and

radiation, also allergies and immune disorders


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Regional Enteritis (Crohns disease):Occurs anywhere along the GI tract mostcommon in distal ileum and colon

Chronic inflammation that extends through alllayers of bowel wall

Periods of remission and exacerbation, ulcersform on inflamed mucosa, separated bynormal tissue,

Advanced cases the bowel wall thickens andbecomes fibrotic, intestines narrow


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Crohns Disease


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Regional Enteritis (Crohns disease):

Clinical Manifestations: lower right quadrantpain, diarrhea unrelieved with defecation,colon spasm, result in decrease PO intake,malnutrition, wt loss, steatorrhea, abscesses

and fistulas Assessment and Diagnostic: Stool sample,

barium swallow or enema, CT scan, CBC,albumin

Complications: Intestinal obstruction, fluid &electrolyte imbalance, malnutrition, fistulaand abscess formation, increase risk coloncancer


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Ulcerative

Colitis: recurrent ulcerative andinflammatory disease of the mucosal and

submucosal layers of colon and rectum

Multiple ulcers occurring one after the other,diffuse inflammation, usually begins in rectumand spreads proximally to entire colon;abscesses form and eventually the bowelnarrows and shortens


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Ulcerative Colitis


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Ulcerative Colitis:

Clinical Manifestations: Exacerbation andremission, diarrhea and left lower quadrantpain, rectal bleeding, anorexia, wt loss,dehydration, 10-20 liquid stools/day

Assessment and Diagnostic: Assess hydration,nutritional status, signs of bleeding, stoolspecimen, CBC, Sigmoidoscopy, Colonoscopy,CT scan

Complications: Toxic megacolon, perforation,bleeding, vomiting, fatigue


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Medical Management of Chronic IBD:Reduction of inflammation, provide rest fordiseased bowel, preventing complications

Nutritional Therapy: Oral fluids, lowresidue, high protein and calorie diet withvitamin and iron supplements

Pharmacologic Therapy: Sedatives andantidiarrheal meds, Aminosalicylates suchas sulfasalazine (Azulfidine), mesalamine(Pentasa) are used for long term

maintenance. Corticosteroids (prednisone)also help reduce inflammation


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Surgical Management: May require

total colectomy (removal of entirecolon) and placement of ileostomy;

Nursing Management: goals;prevention of fluid volume deficit,maintenance of optimal nutrition andwt, avoidance of fatigue, promoting

effective coping


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Small Bowel Obstruction

Intestinal contents, fluid, gas accumulate above the

intestinal obstruction: Adhesions, Intussusception,Volvulus, Hernia, Tumor are all causes of obstruction.

Clinical Manifestations: Cramping pain, pass bloodand mucus but no stool, vomiting (intestinal

contents), dehydration, abdominal distention Medical Management: Decompression of bowel

through Nasogastric (NG) tube, if obstruction iscomplete then surgical intervention is warranted

Nursing Management: maintain function of NG tube,assess for fluid and electrolyte imbalance


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Large Bowel Obstruction

Obstruction of larger bowel is similar to small

bowel obstruction, however the symptomsdevelop and progress relatively slowly

Constipation may be only symptom for days,eventually abdominal distention and vomitingof fecal contents

Colonoscopy may be performed to untwistand decompress bowel

Usual treatment is bowel resection to removethe obstruction, colostomy may be necessary


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Polyps of Colon and Rectum

Polyp is a mass of tissue that protrudes into

lumen of bowel Can occur anywhere in colon or rectum

Neoplastic (carcinomas) or non-neoplastic(benign)

Most common sign rectal bleeding

Diagnosis based on digital rectal exam,colonoscopy, barium enema

Polyps should be removed either throughcolonoscopy or laparoscopy


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Polyps of the colon


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Diseases of the Anorectum

Anorectal abscess: obstruction of anal gland,infection, deep abscesses may result in low

abdominal pain and fever Treatment include incision and drainage, sitz

baths and analgesics

Anal fistula: Tiny, tubular tract that extends into the

anal cavity from an opening located beside the anus,usually result from an infection

Surgery recommended for removal of fistula,wound is packed with gauze

Anal fissure: longitudinal tear or ulceration in the

lining of the anal canal, caused by large firm stool, orchildbirth or trauma

Most heal with management by stool softener, sitzbaths and increase fluid intake


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Diseases of the Anorectum

Hemorrhoids: dilated portions of veins in the

anal canal. Increased pressure in thehemorrhoidal tissue due to pregnancy mayinitiate or aggravate hemorrhoids

Two types: internal and external

Cause itching and pain, most commoncause of bright red bleeding withdefecation

High fiber diet, increase fluids, bulklaxatives, sitz baths, may require rubberband ligation or more extensive surgery


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Hemorrhoids


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Treatment for hemorrhoids

AssessmentAndManagementOfPatientsWithLowerGI [EDocFind.com]

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