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NCM 116 - GIT (MODULE 5 Part II)
NCM 116 - GIT (MODULE 5 Part II)
Module 5: Nursing Care Management of Clients with assessment of active anorectal function
Nutrition & Gastro-intestinal Problems (Part II) Pelvic floor magnetic resonance imaging
(MRI) - identify occult pelvic floor defects
DISTURBANCES IN ABSORPTION AND FECAL INCONTINENCE (Medical
ELIMINATION Management)
DISORDER OF INTESTINAL MOTILITY no known cure; specific management -
FECAL INCONTINENCE quality of life
IRRITABLE BOWEL SYNDROME related to diarrhea - disappear when diarrhea
MALABSORPTION SYNDROME is successfully treated
STRUCTURAL AND OBSTRUCTIVE frequent symptom of a fecal impaction -
BOWEL DISORDERS After removal of impaction and the rectum
INTESTINAL is cleansed, normal functioning of the
OBSTRUCTION anorectal area can resume
DIVERTICULAR DISORDERS Biofeedback therapy w/pelvic floor muscle
training - if the problem is decreased
DISORDER OF INTESTINAL MOTILITY sensory awareness or sphincter control
Surgical procedures: surgical
FECAL INCONTINENCE reconstruction, artificial sphincter
involuntary passage of stool from the rectum implantation, sphincter repair, or fecal
Influencing factors: ability of the rectum to diversion
sense and accommodate stool, the amount and FECAL INCONTINENCE (Nursing
consistency of stool, the integrity of the anal Management)
sphincters and musculature, and rectal motility Goal: help patient achieve fecal continence;
embarrassing and socially incapacitating manage problem so patient can have
FECAL INCONTINENCE (Pathophysiology) predictable, planned elimination
In general, it results from conditions that suppositories (sometimes)- stimulate the
interrupt or disrupt the structure or anal reflex; D/C if regular schedule
function of the anorectal unit (Beitz, 2006) achieved
Causes: trauma (eg, after surgical Bowel regulation: initiate bowel-training
procedures -rectum), neurologic disorders program that involves setting a schedule;
(eg, stroke, multiple sclerosis, diabetic therapeutic use of diet & fiber
neuropathy, dementia), inflammation, o Foods that thicken stool (eg,
infection, chemotherapy, radiation applesauce) and fiber products
treatment, fecal impaction, pelvic floor o (eg, psyllium) help improve continence
relaxation, laxative abuse, medications, or maintain skin integrity, esp. in the
advancing age. debilitated or elderly patient: incontinence
FECAL INCONTINENCE (Clinical briefs/ diapers (brief period); meticulous
Manifestations) skin hygiene; use of perineal skin cleansers/
minor soiling, occasional urgency and loss protection products
of control, or complete incontinence If continence not achieved - assist patient
poor control of flatus, diarrhea, or and family to accept and cope with chronic
constipation. situation
ASSESSMENT & DX. FINDINGS Fecal incontinence devices (Flexi Seal
Flexible sigmoidoscopy - rule out tumors, Fecal Management System)
inflammation, or fissures o External devices - special rectal
X-ray studies: barium enema, CT, anorectal pouches, called fecal incontinence
manometry, and transit studies - identify collectors (drainable)
alterations in intestinal mucosa and muscle o Internal drainage systems - eliminate
tone or detect structural or functional fecal skin contact; especially useful
problems when there is extensive excoriation or
Anorectal manometry (ie, pressure studies skin breakdown
such as a balloon expulsion test) may be
performed to assess malfunction of the
sphincter
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IRRITABLE BOWEL SYNDROME (IBS) IBS (Medical Management)
occurs more commonly in women than in men, Goals: relieve abdominal pain, control
and the cause remains unknown diarrhea or constipation, and reduce stress
Factors associated: heredity, psychological stress Restriction and then gradual
or conditions (depression and anxiety), a diet reintroduction of foods that are possibly
high in fat and stimulating or irritating foods, irritating - (eg, beans, caffeinated products,
alcohol consumption, and smoking corn, wheat, dairy lactose, fried foods,
IBS (Pathophysiology) alcohol, spicy foods, aspartame)
The change in motility may be related to High-fiber diet - help control the diarrhea
neuroendocrine dysregulation, especially if and constipation Exercise - reduce anxiety
there are changes in serotonin signaling and increase intestinal motility Stress
Changes in intestinal motility may also reduction or behavior modification program
result from infections or other Hydrophilic colloids (ie, bulk) and
inflammatory disorders or vascular or antidiarrheal agents (eg, loperamide)-
metabolic disturbances control the diarrhea and fecal urgency
Peristaltic waves are affected at specific Anticholinergics or antispasmodics (eg,
segments of the intestine and in the propantheline [Pro-Banthine])- decrease
intensity with which they propel the fecal smooth muscle spasm, cramping and
matter forward constipation
No evidence of inflammation or tissue Antidepressants - assist in treating
changes in the intestinal mucosa underlying anxiety and depression …
IBS (Clinical Manifestations) Tegaserod - increased risks of MI and stroke
Primary symptom: alteration in bowel Probiotics (Lactobacillus and
patterns: constipation, diarrhea, or a Bifidobacterium) - decrease abdominal
combination of both. bloating and gas
abdominal pain is sometimes precipitated by Complementary medicine - artichoke leaf
eating and is frequently relieved by extract, peppermint oil, and caraway oil
defecation IBS (Nursing Management)
bloating, and abdominal distention often provide patient and family education
accompany changes in bowel pattern teach & reinforce good dietary habits (eg,
IBS (Assessment & Dx. Findings) avoid food triggers)
Criteria - recurrent abdominal pain or keep a symptom and food diary for 1 to 2
discomfort for at least 3 days a month in weeks
the past 3 months, including two or more of encouraged patient to eat at regular times
the following: and to chew food slowly and thoroughly
o (1) improvement with defecation; fluid should not be taken with meals because
o (2) onset associated with change in this results in abdominal distention
frequency of stool; and discourage alcohol use and cigarette
o (3) onset associated with change in smoking
appearance (form) of stool
stress management - relaxation techniques,
o (Laine & Goldman, 2007; Spiller, 2007).
yoga, or exercise
Definite diagnosis requires tests that
confirm absence of structural IRRITABLE BOWEL DISEASE
or other disorders.
o Stool studies, contrast x-ray studies, and
proctoscopy - to rule out other colon
diseases
o Barium enema and colonoscopy - reveal
spasm, distention, or mucus
accumulation in the intestine
o Manometry and electromyography
(EMG) - study intraluminal pressure
changes generated by spasticity
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MALABSORPTION (Assessment & Dx
Tests)
Stool studies for quantitative and qualitative
fat analysis, lactose tolerance tests, D-
xylose absorption tests, and Schilling tests.
Hydrogen breath test - if carbohydrate
malabsorption suspected
Endoscopy with biopsy (best diagnostic
tool)
o Biopsy of the small intestine is
performed to assay enzyme activity or
to identify infection or destruction of
mucosa
Ultrasound studies, CT scans, and x-ray
findings - reveal pancreatic or intestinal
MALABSORPTION SYNDROME tumors that may be the cause
Inability of the digestive system to absorb one or CBC - detect anemia
more of the major vitamins (especially A & Pancreatic function tests - assist in Dx. of
B12), minerals (ie, iron and calcium), and specific disorders
nutrients (ie, carbohydrates, fats, and proteins) MALABSORPTION (Medical Management)
CATEGORIES: avoid dietary substances that aggravate
Mucosal (transport) disorders causing malabsorption; supplement lost nutrients
generalized malabsorption (eg, celiac sprue, Common supplements are water-soluble
regional enteritis, radiation enteritis) vitamins (eg, B12, folic acid), fat-soluble
Infectious diseases causing generalized vitamins (ie, A, D, and K), and minerals (eg,
malabsorption (eg, small bowel bacterial calcium, iron)
overgrowth, tropical sprue, Whipple’s Primary disease - managed surgically or
disease) nonsurgically
Luminal disorders causing malabsorption
Dietary therapy - aimed at reducing gluten
(eg, bile acid deficiency, Zollinger-Ellison intake (celiac sprue) Folic acid supplements
syndrome, pancreatic insufficiency) - tropical sprue
Postoperative malabsorption (eg, after
Antibiotics (eg, tetracycline [Tetracyn],
gastric/ intestinal resection) ampicillin [Polycillin]) - treatment of
Disorders that cause malabsorption of tropical sprue and bacterial overgrowth
specific nutrients (eg, disaccharidase syndromes
deficiency leading to lactose intolerance) Antidiarrheal agents - decrease intestinal
MALABSORPTION (ClinicalManifestations) spasms Parenteral fluids - dehydration
Hallmarks: diarrhea or frequent, loose, treatment
bulky, foul-smelling stools that have MALABSORPTION SYNDROME
increased fat content and are often grayish (Gerontologic Considerations)
often with associated abdominal distention, The older patient may have more subtle
pain, increased flatus, weakness, weight symptoms of mal- absorption that may be
loss, decreased sense of well-being extraintestinal, including fatigue and
chief result - malnutrition confusion
o manifested by weight loss and other Medical management may include the
signs of vitamin and mineral deficiency administration of corticosteroids, which
(eg, easy bruising, osteoporosis, may cause a host of adverse effects such as
anemia) hypertension, hypokalemia, and mood
untreated - patient becomes weak and changes
emaciated because of starvation and Antibiotics may reduce vitamin K–
dehydration producing intestinal flora, resulting in a
Failure to absorb the fat-soluble vitamins A, prolonged prothrombin time (PT) and
D and K causes a corresponding international normalized ratio (INR) if the
avitaminosis. patient is concurrently taking warfarin
(Coumadin)
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Urinary retention, altered mental status,
or glaucoma may occur as adverse effects
of anticholinergic drug therapy in older Intussusception One part of the
people. intestine slips into
MALABSORPTION(Nursing Management) another lower part.
provide patient and family education The intestinal lumen
regarding diet and the use of nutritional narrows.
supplements
Volvulus The bowel twists and
o include information about the risk of
turns on itself,
osteoporosis related to malabsorption of
obstructing the
calcium
intestinal lumen. Gas
monitor patients with diarrhea for fluid and and fluid accumulate
electrolyte imbalances in the trapped bowel
conduct ongoing assessments to determine
whether the clinical manifestations related
Hernia The intestine
to the nutritional deficits have abated
protrudes through a
weakened area in the
abdomen muscle or
STRUCTURAL AND OBSTRUCTIVE BOWEL wall.
DISORDERS
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Locally, the increased pressure pushes ABG - Metabolic alkalosis
electrolyte-rich fluid from the intestine and CBC - increased WBC count (infection)
capillaries into the peritoneal cavity. Hct - elevated if dehydration develops
Failure of the mucosa to reabsorb the INTESTINAL OBSTRUCTION (Medical/
secretions contributes to water and Surgical Management)
electrolyte imbalances and shock. NPO
Increasing pressure on the bowel from IV fluids with electrolytes - correct
severe distention and edema impairs imbalances; antibiotics (infection)
circulation and leads to necrosis and Intestinal decompression- relieve intestinal
eventually gangrene of a portion of the distention, cramping, and vomiting, and
bowel. reduce the potential for intestinal rupture
Perforation of the gangrenous bowel, which with peritonitis
results from pressure against weakened o accomplished by suctioning large
tissue, causes the intestinal contents to seep amounts of accumulated secretions and
into the peritoneal cavity, resulting in gas through NGT or longer intestinal
peritonitis tube
INTESTINAL OBSTRUCTION (Assessment Mechanical obstructions may be treated
Findings) during colonoscopy - removing obstructing
Nausea and abdominal distention polyps or destroying benign tumors with
Vomiting - when obstruction occurs high in laser therapy or electrocautery
the GIT Surgery - a section of the obstructed bowel
(stomach and small intestine) is removed and then the proximal and distal
o emesis appears to contain bile or fecal sections are reconnected (bowel resection
material and anastomosis).
Lower GIT obstruction - vomiting may o In some cases, a temporary or
occur later/ not 1-2 BM soon after the permanent ostomy may be performed.
intestine has been obstructed severe INTESTINAL OBSTRUCTION (Nursing
intermittent cramps Management)
Perforation symptoms- sudden, sustained Documenting all symptoms and obtaining
pain, abdominal distention, and fever detailed information.
Functional obstruction- absent bowel manage pain - maintain patency of
sounds decompression tube; administer prescribed
Mechanical obstruction, the bowel sounds narcotic analgesics
usually are high- pitched above the maintain fluid balance -prevent deficits
obstructed area. Pulse and respiratory rates related to fluid shifts and losses from
(elevated). BP falls, and urine output vomiting
decrease (shock) help the client deal with fear related to
Large bowel obstruction - symptoms occur severe, possibly life-threatening symptoms
more slowly and an unstable condition
o Constipation may be the only symptom maintain uninterrupted IVF infusion
for many days monitor urinary output hourly
o Eventually the client experiences
abdominal distention, lower abdominal DIVERTICULAR DISORDERS
cramps and pain. Diverticula are sacs or pouches caused by
o Fecal vomiting may occur herniation of the mucosa through a weakened
o Shock symptoms portion of the muscular coat of the intestine or
INTESTINAL OBSTRUCTION (Diagnostic other structure
Findings) can appear anywhere in the GI tract, but appear
Radiographic study of the abdomen - shows most commonly in the colon (sigmoid area), in
air and fluid collecting in a segment of the people older than 50 years of age
intestine DIVERTICULOSIS/ DIVERTICULITIS
Barium enema (used when the risk of Asymptomatic diverticula are called
perforation is low) pinpoints location of the diverticulosis. When the diverticula
obstruction. become inflamed, the term diverticulitis is
Serum electrolytes - low levels of Na, K, Cl used.
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DIVERTICULAR DISORDERS Surgery - non responsive to medical
(Pathophysiology & Etiology) treatment, or if complications (perforation,
o low dietary fiber intake (higher intestinal obstruction, or severe bleeding)
incidence) occur
o congenital predisposition o The portion of colon that contains the
o result from weakness in the muscular diverticula is removed, and the
coat (aging) continuity of the bowel is reestablished
Diverticula become inflamed when fecal by joining the remaining portions of the
material is trapped in one or more blind colon
pouches Continuity of the bowel is restored -
Inflammation causes swelling of the tissue colostomy is closed 3 to 6 weeks later
in the area DIVERTICULAR DISORDERS (Nursing
o several diverticula in one area: severe Management)
edema - intestinal obstruction Take VS - establish a baseline and to
abscesses form - when inflamed tissue determine if the client is febrile
becomes infected with intestinal bacteria examines abdomen - pain, tenderness, and
swollen tissue - rupture or form a fistular masses
connection with adjacent organ (bladder) explain underlying pathology and rationale
DIVERTICULAR DISORDERS (Assessment for treatment
Findings) consult the dietitian for teaching - list of
Constipation alternating with diarrhea, foods to eat and avoid
flatulence, pain and tenderness in the LLQ, surgery - prepare client before surgery and
fever, and rectal bleeding manages the postoperative care
palpable mass may be felt in the lower Include the following points in the teaching
abdomen plan:
Bleeding diverticula - maroon o Follow the diet recommended by the
stool/resembling ‘‘currant jelly’’ physician( reduce pain and discomfort)
Barium enema - shows an irregular mucosal o Bran adds bulk to the diet
wall o Avoid use of laxatives or enemas -
Colonoscopy - visualize the areas of except when recommended by physician
inflammation o Avoid constipation - do not suppress the
CT scan - generally used first as an urge to defecate
alternative; avoid perforation o Drink at least 8 to10 large glasses of
CBC -leukocytosis fluid each day.
Stool specimen - occult blood o Take prescribed medications as directed,
DIVERTICULAR DISORDERS even if symptoms improve.
(Medical/Surgical Management) o Exercise regularly if the current lifestyle
No symptoms - no treatment is somewhat inactive.
Avoid foods that contain seeds of any kind o If severe pain or blood in the stool
High-fiber diet supplemented with bran or occurs, see a physician immediately.
prescription of a bulk-forming agent (e.g.,
Metamucil) - helps avoid constipation
When symptoms occur - diet is temporarily
adjusted to low-residue foods
Severe inflammation and accompanied by
pain and local tenderness - IVF for several
days; NPO
o As the inflammation subsides with
antibiotic therapy, oral fluids and food
are reintroduced