NRS - MEDICAL SURGICAL NURSING II (LEC)

GI DISORDERS CONTINUATION (PLM-CN BATCH 2020) NRS 3217-9

OUTLINE kapag kumakain tayo ng gulay ay either sobrang hugas/ lutong-

GI DISORDERS IV. Diverticulitis luto and we must be sure that it must be organic.
CONTINUATION A. Predisposing Factors o Based on recent studies, this has a high incident rate among
I. Inflammatry Bowel Disease B. Clinical smokers.
A. Incidence Maniffestations  Can occur anywhere in the colon
B. Etiology C. Diagnostics o Common in the colon, in the ilium per se ‘yan ‘yung common
II. Regional Enteritis D. Management area niya, but it can actually occur anywhere in the colon. If it's
A. Incidence E. Complications in the intestine it is either into the small intestine or into the large
B. Signs and Symptoms F. Nursing intestine.
III. Ulcerative Colitis Considerations
A. Cause V. Colorectal Cancer SIGNS AND SYMPTOMS
B. Incidence A. Pathophysiology  Prominent RLQ pain
C. Signs and Symptoms B. Clinical Manifestations o The predominant s/s is the RLQ pain
D. Complications C. Diagnostics o People would describe this as a grumpy abdominal pain
E. Regional Enteritis vs D. Management and  Diarrhea unrelieved by defecation
Ulcerative Colitis Surgical Management o When we have diarrhea or abdominal pain, pag naka focus
F. Management and tayo the pain will become intense, then mamaya pag
Nursing Management nakakaipon nanaman masakit nanaman. But in this particular
incident, even after you have defected the pain is still constant.
 We also notice that there is steatorrhea (excessive amount of
GI DISORDERS CONTINUATION fat in your poop) on these particular patients
INFLAMMATORY BOWEL DISEASE ULCERATIVE COLITIS
 Caucasian and Jews  Recurrent ulcerative and inflammatory disease of the submucosal
o people affected with this. layers of the colon and rectum
 Afro-Americans and Asians o Serious disease if this is accompanied by a systemic
o people affected at present based on statistics. complication.
 Women- 10-30 years old o It has a higher mortality rate.
o maybe because of diet. o Whenever you have ulcerative colitis, it could lead to colon
cancer in about 10–15%
INCIDENCE
 Increased incidence in the past century. CAUSE
 10,000 to 15,000 cases annually. o The exact cause was not fully understood until this present
advancement in medicine.
ETIOLOGY o Experts believe that it has an involvement with combinations of
1. Environmental factors genes and the environment, including immune factors.
o Due to pesticides in food, food additives, smoking (even o The immune system is mistakenly triggered by the
2nd hand smoking), and radiation. inflammation of the colon, leading to symptoms and damage to
2. NSAIDs the intestinal lining, so there are progressions up until the
o Exacerbate IBD development of cancer.
o Because it is an ulcerogenic medication which causes o The goal of treatment is to reduce inflammation and control
inflammation. symptoms so that we can achieve and maintain remissions.
3. Immunologic and Auto-immune Disease o Treatment options include:
o Sometimes our body has an abnormal response to the o Medications
dietary and bacterial antigen that we encounter in our day-  Anti-inflammatory drugs: Aminosalicylates
to-day living.  Corticosteroids
4. Genetics  Immunomodulator
o Dietary modifications
REGIONAL ENTERITIS o Surgery (if the form is severe): Colectomy
 Other terms: Crohn’s Disease, Granulomatous Colitis
o This is subacute/ chronic which means that it undergoes certain INCIDENCE
period of time that extend through the layer of the bowel from  Caucasian, Jews; -30-50y/o
the intestinal mucosa.
o The inflammation started from the intestinal mucosa then it SIGNS AND SYMPTOMS
extend up until the layer of the entire bowel. 1. Diarrhea - approximately 10-20 liquid stool per day
o It has a period of remission and excacerbation (bumabalik then 2. LLQ pain
nawawala). 3. Rectal bleeding – patient may have rectal bleeding secondary
to frequent defecation
INCIDENCE 4. Intermittent tenesmus (feeling of cramping and urgent need to
 Young adolescents/ young adults, women defecate)
o dahil medyo picky pa sa pagkain, and with this particular age
ayaw pa nilang masyadong tumaba so they are more on eating COMPLICATIONS
vegetables, pero minsan may pesticides ito/ hindi masyadong
 Toxic Megacolon - has high mortality rate
nahugasan kaya meroong mga uod na nakakain, kaya dapat o Extensions of inflammatory process down up until the
muscular layer

TRANSCRIBED BY: Group 1, Group 2, Group 3

 o Inhibiting contractions causing distention
 Signs and Symptoms: Fever, abdominal distention, vomiting,
pain, fatigue
 Colonic Perforation
o A complication of toxic megacolon
o High mortality rate, about 50% of patients who develop
this die
 Management:
o NGT suctioning, Antibiotics, IVF w/ electrolyte
replacements, steroids
 Whenever px have colonic perforations, we
have to do certain surgical operations,
aside from the medical management that
we can actually do like ngt, suctioning; para
madecompress natin.
 We need to give antibiotic — pag nag
perforate you are swimming with your own
sh*t which is why pt may develop sepsis.
 Secure the intravascular compartment with
IV as well as the replacement of serum and
electrolytes.
 Steroids are debatable because if we give
steroids the immune response of the pt
decreases. pt is already having massive
infections, nagiging immunocompromised
si pt.
 ADDITIONAL INFO: According to GLR’s
surgeon friends, if they don’t give steroids,
they cannot control the inflammation,
cannot proceed with the operation.
hanggang namamaga, yung suture na
gagamitin for the colon surgery, hindi niya
mamamaintain, magrurupture lang siya ng
magrurupture or puputok.
 Steroids - immunomodulators, napapababa
yung immune system > prone to develop
infections — yung may mga asthma,
inflammation, massive inflammation, pag
nakasteroid therapy, pinapaiwas sa
crowded area because it is easy to acquire
respiratory infections.
o Surgery
 Surgery is being done particularly, total
colectomy, if the patient is unresponsive to
medications, 24 to 48 hours, on the toxic
megacolon. But if we are talking about
colonic perforations, wala nang ibang
choice kundi mag-undergo ng surgery.
 So, surgery is being done after 24 to 48
hours, wherein the patient is unresponsive
to the medications and medical
management done (only if it is a toxic
megacolon).
 Bottom line is kapag colonic perforation,
surgery na agad, ‘di pwedeng medical
management lang, may butas or nag-
perforate na, so we need surgical
intervention para isarado yung nag-
perforate.
REGIONAL ENTERITIS (CROHN’S DISEASE VS. ULCERATIVE
COLITIS
o This is the difference between regional enteritis (Crohn's
disease) and ulcerative colitis.
Pathology:
o The extent of that pathology is on the transluminar and
ulcerative colitis, you have mucus ulcerations.
Site:
o Regional Enteritis (RE): On the side is in the ileum and
ascending colon;
o Ulcerative Colitis (UC): The most common affected side is
lower colon up until to the rectum (hanggang sa puwet)
Cause:
o RE: cause is unknown, but associated with jewish genes and
environment.
o UC: the cause is unknown too but we associate this with familial
history, jewish ethnic, and also emotional stress.
Age:
o RE: 20-30, 40-60 y/o
o UC: 15-40 y/o
Bleeding:
o RE: On the bleeding tendency, regional enteritis, the stool is
more on mucoid or with pus, rather than with a bleed, so there
is a decreased tendency that you will see bleeding. If there is
bleeding present, bleeding is very minute, so commonly
nakikita sa guaiac examination into your fecal occult blood test
(FOBT)
o UC: In ulcerative colitis there is a severe possibility of because
we are talking about the toxic megacolon and perforations. We
are talking about ulceration. If there is ulcerations there is a
possibility of bleeding.
Perianal Involvement:
o RE: there is high chances to the perianal involvement
o UC: On the ulcerative colitis there is a mild involvement
Fistula:
o “pagbubutas”
o RE: Merong anal involvement kaya merong common fistula
o UC: Rare
Rectal Involvement:
o RE: merong 100% rectal involvement
o Question: Bakit nagkakaroon ng fistula?
o Answer: Kasi merong perianal; peri = sa paligid, not
really in the rectum per se
Diarrhea:
o RE: 5-6 stool/day
o UC: 20-30 watery stool/day
Abdominal Pain 7 Weight Loss:
o RE & UC: They both have exhibited abdominal pain and weight
loss because we are still dealing with absorptions of medications,
nutrients, serum electrolytes and fluids.
Interventions:
o DIET: Same diet modifications; if px is a candidate for a certain
surgical procedure, crucial to monitor TPAG (total protein
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 albumin globulin), as if it is in abnormal range, px has difficulty
of surviving the operation, and any untoward complications that
may happen. TPN to manage TPAG
 In Sir GLR’s father case - suture after
anastomosis ay napatid/marupok,
natanggal ang tahi; nagleak sa surgical side
yung fecaloid material, an accurate
indication of ANASTOMOSIS LEAKAGE.
INTERVENTION: another surgery to
reopen the site, and double-barrel
colostomy
 Number 1 rule: Di ka pede mag-
anastomosis if there is a presence of
infection.
 Kaya sa OR daw, maririnig naten if dirty
case or clean case. Dirty case means no
anastomosis, because kailangan muna ma-
eradicate ung bacterial presence sa
peritoneum. Kasi ung pinagdikit mo or
pinag-anastomose mo na part ng colon,
ung mga bacteria will release acidic type of
enzyme which is ginagawa nyang marupok
ung suture kaya napapatid ung tahi.
 We provide antibiotic therapy and after
6months -1year (hindi naman daw totally
6months-1year), ine-ensure lang naten na
wala nang infection and we give time for the
body to recover dahil hindi ren pwedeng
anesthesia ka lang nang anesthesia.
 Ang takedown ng colostomy is minimum of
6 months to 1 year.
 Pagsinabing takedown of colostomy ay
ibabalik na ulet sya sa dati (eg. tatae na ulet
sya, aayusin na ung colostomy, etc),
however, depende pa ren daw ito sa
situation and complication ng patient.
o TPN: Support nutritional status of the patient. Monitor the T-
PAG if there is abnormality. TPN binibigay naten kapag ang
pasyente ay hindi makakain or kung makakain man, hindi
naman maabsorb ung nutrients ng katawan so ita-tae lang
nang ita-tae (watery stool). No NGT, no osteorized feeding so
naka-TPN talaga tayo.
o STEROIDS: Same
o AZULFIDINE: Same
o ILEOSTOMY:
o RE: Ileostomy or Colectomy
o UC: Ileostomy or Proctocolectomy
MANAGEMENT
o Collaborative Management
NUTRITIONAL THERAPY
o Oral fluids is very necessary
o OFI, IVF, Electrolytes, TPN
o High-caloric, High protein, Low-residue diet, Low-fiber diet
o Low-fiber diet dahil nagtatae si patient, we might
aggravate the situation if we give high fiber diet to the
px
o If px can eat orally, we can give white bread, cereals,
or pasta (high-carb diet)
o We can give vitamin supplements, minerals such as
iron replacement.
o Avoid foods that cause diarrhea. Do not give milk and
cold beverages because there is abdominal pain to
this.
o Ask the patient to stop smoking because it will interfere with the
nutritional management of the patient.
PHARMACOLOGIC THERAPY
A. Sedatives and anticholinergic
o To decrease spasm in the colon area
B. Anti-diarrheal/ Antiperistaltic medications
o Kapag nagtatae, we can give anti-diarrheal or
antiperistaltic medications
C. Sulfonamides/ Aminosalicylate formulation
o Sulfonamides - the antibiotic of choice
o Azulfidine
 very effective for mild to moderate inflammation and
prevents recurrence in the long term
 Used for long term maintenance therapy
D. Corticosteroids -
o To treat severe fulminant disease
E. Immunomodulators
o To alter immune response and prevent relapse.
o Common drugs we give is methotrexate and cyclosporine
SURGERY
 Criteria for surgery:
1.Intractable disease
2.Poor quality of life - if you’re not going to perform operations
3.Complications from disease or from medical management
 Too much steroids, masyado nang bagsak ang immune
system, so we cannot give steroids anymore – instead we
perform operations.
 Regional Enteritis
o 50% of patients with crohn's disease requires surgery
o Surgery of choice is usually total colectomy and ileostomy
 Ulcerative Colitis
o About 15 to 20% will require surgery.
o The surgery of choice is proctocolectomy and ileostomy.
o Another is strictureplasty, what we do in this procedure is that
we widen the narrow area and sections na nablock ng bowel,
leaving the bowel still intact walang cut na ginagawa.
TYPES OF SURGERY
1. Total Colectomy w/ ileostomy
o When we say total colectomy w/ ileostomy, we will remove
the entire colon with the surgical creations of opening of
ilium or small intestine. It will allow the fecal matter to drain
from the ilium to the outside of the body. Mataas yung
colostomy dito kasi ginamit ay small intestine.
o What we expect with this kind of surgery - we have to take
note that if you are taking care of a patient with total
colectomy w/ ileostomy dahil nga nasa small intestine the
fecal matter is watery.
 Small intestine – watery consistency
● Expect mushy drainage with frequent intervals
o Unlike the other na ilang oras pa after kumain,
dito walang interval
 Not all nutrition is absorbed
o Supposedly, absorption occurs until the large
intestine
o Here, absorption stops at small intestine and
goes out immediately
● Management: Monitor nutritional status of the patient
 Provide alternatives: vitamins
● To support nutritional status of pt
● Including serum electrolytes and fluid status
● Management: Advise oral fluid intake after surgery
2. Total Colectomy w/ Continent Ileostomy
 Mage-excise/remove pa rin ng entire colon
 Creation of a continent ileal reservoir
● Gumagawa ng kock pouch
o Wastes stays within body until it is removed
o Medyo popular, but mahirap gawin
 Eliminates the need for an external fecal collection bag (colostomy
bag)
 40 to 30 cm in the distal ileum is reconstructed to form a reservoir
● And then a nipple valve is done
3

o o
o Kock Pouch
 Reconstruction of ileum, creating a reservoir. Nipple valve is them
created and stool can pass through.
 Catheter is used to remove fecal material inside the px. It is inserted
through the nipple valve. There is about 20% chance that the valve
will malfunction, leading to colostomy.
3. Total Colectomy w/ Ileoanal Anastamosis
 Removal of entire colon with anastomosis to the ileum down until
the anus.
 To establish an ileal reservoir and anal sphincter control to retain
elimination.
o Not all surgeries are suitable for patients. Total
Colectomy w/ Ileostomy is more commonly
used. In terms of Continent Ileostomy and
Ileoanal Anastamosis, the length of the
remaining colon is often assessed if the area can
still be preserved including the anal sphincter. If
GI function can no longer be sustained,
colostomy is done.
NURSING MANAGEMENT
 Maintain normal elimination pattern
o Keep, maintain, clean and odor-free
environment.
 Relieve pain
o Administer anticholinergics (usually 30 mins
before meals)
o To eliminate pain, advise the patient to do
frequent position changes.
o Hot and cold application is also advised.
o During hot applications, ensure that the
container doesn’t leak because commonly in the
hospital, it is the cause of injury on the patient
(hot compress can burn patients).
 Encourage and maintain fluid intake
o Assess weight of the patient daily to assess the
signs and symptoms of fluid volume deficit.
 Restrict the activity of the patient as much as possible.
o To conserve the energy
o If hindi restricted ang activity ni patient, mataas
din ang kanyang peristaltic movement.
o Kapag nagrestrict tayo ng activity ni px, we were
able to reduce the caloric requirement of the px
since sometimes yung demand is actually hindi
namemeet duon sa kanyang supply
 Promoting the bed rest
o We have to encourage px to limit activity and to
have intermittent rest period
 Prevent Skin breakdown
o Dahil nga merong possibility of fistula so yung
mga peri- anal hair is very necessary (peri-anal
care)
o Kapag si px naka ileostomy, you can use a
certain skin barrier (pinapahid kay px)
o Emollients to prevent skin breakdown
 Monitor and manage complications
o Monitor vital signs, Input and output, electrolytes
o CBC is very important because we wanted to
know the clotting factor of your px and we do
necessary replacement if needed.
o Monitor post surgery px their s/sx, we wanted to
see if there is perforations or there is bleeding
(hemorrhage)
o Tinitignan natin yung output kung nag
anastomosis (tinitignan natin yung klase nung
tae ni px)
o Advice the px while px is in the hospital, do not
clush, kung tumatayo naman siya, since di
naman siya complete bed rest, we still
encourage to do ambulation that is still
necessary (di dapat sobra sobrang activity)
Pag tumae si px, we advice na huwag munang
iflush dahil kailangan tignan natin

DIVERTICULITIS
 DIVERTICULUM: saclike out pouching of the lining of the bowel that
extends through a defect in the muscle layer
o singular pouch or sac that form on the walls of
colon
 DIVERTICULOSIS: multiple diverticulitis without inflammation or
symptoms
o Refers to a presence of MULTIPLE
DIVERTICULA
o Small pouches in the colon
o Typically asymptomatic, that may go unnotice
unless accidentally seen on imaging tests such
as Colonsocopy and CT scans while being
performed for other reasons (what we call,
accidental finding)
o Individuals aged 60 years old and above have
an increased chance of developing diverticulosis
o 95% of diverticulosis occurs in the sigmoid colon
 DIVERTICULITIS: results from an infection and inflammation of the
diverticulum from food and bacteria retained in a diverticulum
o Conditions that occur when one or more
diverticula become inflamed or infected.
o Inflammation and infection occur because fecal
materias with bacteria get trapped in one or
more of the pouches (diverticula). This leads to
irritations and inflammations, and sometime
massive growth of infection happen.
o Where symptoms occur:
 Abdominal pain (most
especially on the lower side)
 Tenderness
 Fever
 Nausea
 Changes in the bowel habits
 Rectal bleeding
PREDISPOSING FACTORS
● Age - ↑ with age
o Due to degenerative and structural changes,
especially in the circular layer of the colon,
circular muscular hypertrophy occurs.
● Low intake of dietary fiber
o Older individuals tend to think that they cannot
digest well anymore so they lower their intake of
dietary fiber, leading to conditions such as
constipation
● Constipation
o Increases the chances of obstruction in the
intestine.
● Genetic predisposition
CLINICAL MANIFESTATIONS:
 Divided into initial and progressive symptoms
 Commonly, this disorder is asymptomatic in nature
 Symptoms occurs when there is already complications, such as
hemorrhage, abscess, fistula, and obstructions.
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  Usuall cannot be determined immediately and happens during
INTIAL SYMPTOMS accidental findings
1. Chronic constipation  No presence of symptoms/manifestations yet = diverticuLOSIS
 Preceded the development of diverticulosis for many years  Presence of symptoms/manifestations = diverticuLITIS
o For example, three days before defecation; 
always need a follow up checkup. COMPLETE BLOOD COUNT (CBC)
o It is important to have a regular checkup with  Increased WBC/ESR = underlying infection
your gastroenterologist. 
2. Bowel irregularity with bouts of Diarrhea MANAGEMENT
o Constipated then all of sudden experiences  Managed as OPD basis with dietary modifications and medication
diarrhea. therapy.
3. Abrupt onset of crampy pain in the LLQ 1. Rest
4. Low grade fever, nausea and vomiting, anorexia 2. Dietary modification
5. Abdominal distention
 Clear liquid first until inflammation subsides (“mga sabaw”)
 High fiber diet/low fiber diet if inflammation was already resolved
PROGRESSIVE SYMPTOMS
o High fiber diet & low-fat diet because we want to
1. Cramps increase the stool volume (for constipation)
o Constant crampy pain in the entire abdominal o Low fiber diet if the patient has a diarrhea
region. o
2. Narrow stools 3. Pharmacologic Therapy
o Ribbon-like stools – masyadong manipis yung  We can give Analgesics for the pain
dumi kasi masyading mataas na yung o NSAIDs
inflammatory process na nangyayari sa colon o Never give morphine sulfate for diverticulitis
kaya nagiging masikip na yung daanan ng  Antispasmodic
stools. o Hnbb (buscopan)
o Can be seen in Hirschsprung Disease – o Anticholinergic drug (Propantheline bromide)
pediatric cases.  Antibiotics are also given in 7 – 10 days
3. Increased constipation o Broad spectrum so that the coverage is big
o Constipated kasi masyadong masikip na yung o Bulk forming laxatives (bisacodyl)
daanan ng stools.
o Yung pagtatae na mentioned earlier commonly ACUTE CASES
happens after the progressive symptoms.
 Constipated then diarrhea happens.  Acute cases requires hospitalization
4. Weakness, fatigue, and anorexia
5. Mild to severe pain in LLQ Goal: Rest the bowel
o But usually, the cramping sensation occurs in  Resting the bowel can be done by putting the patient NPO.
the entire abdomen.  Oral intake is restored and increased when signs and symptoms
6. Hematochezia subside.
o Bright red stool. 
o Melena – black colored stool. 1. Diet
  Progressive diet – meaning starting from clear liquids first, then
DIAGNOSTICS general liquids, soft diet, then diet as tolerated.
CT SCAN o Progressive diet is usually initiated once
symptoms subsides.
 Choice of imaging; reveals presence of abscess (nana).
o Low fiber diet is also initiated for the bowel to
 rest.
X-RAY (ABDOMINAL X-RAY) o Secure IV Fluids and its correct regulation.
 Can possibly visualize perforations (much clearer in CT scans)
o No need to perform x-ray if CT scan is done. 2. NGT Suctioning
  Done for abdominal decompression, especially to patients with
BARIUM ENEMA (BA ENEMA) abdominal distention and those who often vomits.
 Used to diagnose diverticuLOSIS, NEVER for diverticuLITIS  NGT is hooked in the suction machine and suctioning is done for
 Performed to further evaluate diagnosis of diverticulosis from initial only 15 mins as prescribed by the doctor.
findings (with x-ray)  Before doing the suctioning, make sure that the IV Fluids of the
 It shows narrowing of the colon and thickening of the muscular layer patient is full of electrolytes and monitor electrolyte levels from time
of colon to time (every 2 or 3 days).
o Thickening of muscle layer due to inflammations o If the doctor has no order for electrolyte
that may later lead to perforation monitoring, the nurse shall call the doctor’s
 NOT for diverticuLITIS since it may possibly cause perforations attention.

3. Pharmacologic Management
COLONOSCOPY
 Same or OPD basis
 Used to diagnose diverticuLOSIS and NEVER for diverticuLITIS  Antispasmodics, analgesics, bulk-forming laxatives, and antibiotics
since it may cause rupture of the colon o It is just slightly different with the prescription of
o Mataas ang pressure tapos magang-maga antibiotics as there might be a longer course of
tapos mag-iinsert ng tubo from anus to colon = medication.
possible rupture ● For bulk-forming laxatives, there shall be I/O and
 Perfomed to visualize the colon to determine the extent of the electrolyte monitoring as some doctors orders enema with
damage and to rule out other pathologic conditions that might be this if there is no possibility or inflammation is not too
present severe.
 o Enema cannot be prescribed if inflammation is
DiverticuLOSIS vs. DiverticuLITIS too severe. If the patient has abdominal pain and

5
 distention and episodes of vomiting, massive
inflammation is present, meaning enema cannot
be given
4. Promoting normal stools
 Through using valve-forming stool or instilling warm oil
(castor oil) into the rectum
o We want to diminish the valve of the stool that is
why fecal masses are softened so that it will not
accumulate inside
 This refers to Elimination; we want to reduce the bacterial
flora in the intestine
o There is a normal bacterial flora in the intestine
however, they increase in number when they do
not get eliminated--until it is abnormal for the
body
Surgical Management:
 Done only when complications occur
ONE-STAGE RESECTION
 We are going to remove the inflamed area with end-to-end
anastomosis
 Putol --> Putol --> Dugtong
MULTIPLE STAGED PROCEDURE
 The doctor will do resections of the inflamed area with NO
anastomosis
 Both ends of the bowel ay ilalabas into the abdomen and create
a stoma. This is called a Double-Barrel Colostomy
o Anastomosis will be performed later on
o Magkaibang side dapat, di pwede sa same side
 Putol --> Putol --> Create Stoma --> DB Colostomy
 o Board Exam Question: What is the most
COMPLICATIONS
 Perforation
o The inflamed area is already ruptured into the
diverticulum
o In here you will experience mild to severe pain and
the pain is localize into the involved segment of your
colon. So, the doctor or nurse do not palpate because
of rupture but if it needed, we only do light palpation.
o You also have to feel the temperature
 Abscess
o Is the result of perforation because of leakage of
infection and contents into the peritoneum that is
why it can also result to abscess
 Peritonitis
o You do not have any bowel sounds of the
patient.
o Expect the signs and symptoms of shock.
o If there is a leask there is a possibility of shock.
o All kinds of shoick will lead into SEPTIC SHOCK
 Hemorrhage
o We need to monitor, because of the inflamed
diverticulum nagkakaroon ng erosion most
especially sa adjacent aterial branaches.
o If the arterial branches are damaged
magkakaroon ka ng massive rectal bleeding.
(parang may regla yung lalaki)
NURSING CONSIDERATIONS
 Maintaining normal elimination pattern
o Normal elimination patter (normal fluid intake 2
to 3 liters per day,)
o Give soft food that is high fiber. But we need to
check the patient status. We don’t give low fiber
diet to a constipated patient.
o We do enema, most especially oil retention
enema.
 Castor oil is used wherein ipapasok ‘to sa
pwet ng pasyente and hahayaan muna ito
roon.
 Advise the patient na huwag umiri at
hayaan lang doon [castor oil].
 If there is a leakage, put a pad so that it will
not be irritating for the patient.
 Oil enema helps in softening the stools.
This will help the patient to defecate easier
and quickly.
 Relieving Pain
o Analgesics can be given.
 Monitoring and Managing Potential complication
o Watch out for signs and symptoms of
perforation.
 This will give us a hint that there is a need
for surgical emergency to our patient.
COLORECTAL CANCER
 Tumors of the colon and rectum relatively common.
o Especially in the Western culture.
o This also has high incidence with patient that
have colon cancer.
Incidence
 Increase with age - > 85 y/o
o In research literature, >40 y/o individual also
have a great risk of developing this cancer.
o Before, it was more common among male but
nowawayds this is not true because of the
lifestyle that we have.
 Most commonly in our age group (20s).
 Higher for people with history of Colorectal CA, IBD, polyps
 Unknown cause
common site for colorectal cancer?
 Rectosigmoid area (rectum and sigmoid)
 About 70% of colorectal cancer occurs in this particular area.
Risk Factors
 Increasing Age
o >40 y/o (this will be followed than the >85 y.o)
o With regards to >85, if may chances na sa >40
y/o, mas magiging higher pa once age
increases.
 Familial History of Colorectal CA, polyps
 Previous colon CA or adenomatous polyps
o Adenocarcinoma, polyps, chronic constipation
 History of IBD
 High fat, high CHON (beef), High refined CHO, low fiber diet
 Genital CA or Breast CA in women
o Has cancer with other origin (reproductive
cancer in women)
o The colon is near the uterus thus faster
metastasis can occur.
 Metastatic cancer = a form of cancer from
other origin
 Obesity
 Chronic Constipation
PATHOPHYSIOLOGY
 95% adenocarcinoma
o 95% of the tumors are a form of
adenocarcinoma for pt with tumors in the colon
to rectal area
 Arising from the epithelial lining of the intestines
 Start as a benign polyp and may become malignant
o Once 40, it is important to have a yearly
colonoscopy for early detection of polyps.
o Colorectal cancer has the highest chance of
survival if caught early
6
  polyps’ resection best chances of survival
GUIDELINES FOR EARLY DETECTION OF COLORECTAL
CANCER
 Digital rectal examination yearly after age 40
o Internal Examination = kinakapa ni doctor
 Occult blood test yearly after age 50
o If 40-year-old  3 consecutive times normal
result  recommended is every 5 years
o If 40-year-old  not normal; with polyps  do it
yearly
 Proctosigmoidoscopy every 5 years after age 50, following 2
negative results of yearly examination.
CLINICAL MANIFESTATIONS
 Change in bowel habits
o Common initial symptom, that is why it’s
important to observe your stool to be aware of
the changes in your bowel habit
o Red flags:
 If you defecate everyday before, then it
changes into every 3 days
 If you eat food without having diarrhea
before, then ngayon nagddiarrhea ka na
 Hematochezia/melena
o Late manifestations
 Unexplained anemia
o If there is low CBC with no active bleeding,
HCPs will look for further reasons
o Commonly, it’s because of the CANCER
o Sometimes, pt is not aware that his/her stool is
color black for a period of time which indicates
bleeding. There is leak, that’s why pt has anemia
 Anorexia, wt loss, fatigue
o Late manifestations
SX ASSOC. W/ R. SIDED LESIONS
 Dull abdominal pain
o Masakit yung tyan na hindi maintindihan
 Melena
SX ASSOC. W. L SIDED LESIONS (OBSTRUCTION)
o Left sided lesions - higher possibility of
obstructions
 Abdominal pain and cramping
 Narrowing stools
o Ribbon-like stool
 Constipation
o Consistent constipation
 Distention
 Hematochezia
SX. ASSOC W/ RECTAL LESIONS
 Tenesmus
 Rectal pain
o There is pain when touching it to the extent that
there may be lump (bukol) already
 Feeling of incomplete evacuation after a bowel movement
o Evacuated incompletely due to obstruction by
the lump
 Alternating constipation and diarrhea
 Hematochezia
o Another constant manifestation
DIAGNOSTICS
 Physical examination
o Very important, together with HISTORY
TAKING, to be able to have congruent data in
diagnosing the pt
o In NCP, do an ASSESSMENT first prior to doing
your diagnosis. Do not preempt your diagnosis!!!
o Always support your diagnosis w/ assessment
(subjective and objective data)
o Abdominal and rectal exam
 Including internal examination (IE)
 Fecal occult blood testing
 Ba Enema
 Proctosigmoidoscopy and Colonoscopy w/ Biopsy
 CEA – reliable indicator of predicting prognosis
o Unreliable indicator in diagnosing CA
o Hindi ito reliable indicator in diagnosing cancer
o Returns to normal after 48H after resection of tumor
o Pag may cancer ka na, para malaman na
maganda prognosis mo, dapat CEA bumababa
within 48 hrs after the incision of the tumor
o If hindi gumagalaw ang CEA mo, panget ang
prognosis mo
o Hindi pwede gamitin as accurate indicator in
diagnosing pt with colon cancer
 Biopsy
MANAGEMENT
 Supportive therapy for intestinal obstruction
o NGT (decompression), blood transfusion (if pt
has anemia)
o Sinusuportahan lang yung manifestations na
pwede mangyari sa pt
 Adjuvant therapy
o There is varied response in adjuvant therapy
o Chemotherapy
o 5FU (Fluorouracil) and 5FU+ Levamisole
(Fluorouracil with Levamisole) are the most common
drug used and very effective in colon cancer
o Radiation therapy
o Ginagawa prior to surgery to shrink the tumor so
that it will be more operable since vascular area
in the tumor will be reduced (lesser bleeding)
o Di pwede operahan pag malaki tumor since
malaki rin BV, once you cut di mapipigil blood >
magkakaoon hemorrhage > possible mamatay
o In some circumstances nagiging close open.
Pag nakitang di pala pwede operahan, close ulit
yung body cavity (Inoperable type /
Unresectable Tumor)
o Used to provide significant relief of the
symptoms. Even if the tumor is unresectable due
to its large size, radiation therapy can shrink
these tumors and reduce the obstruction and
compression on the area.
o An implantable device is inserted into the cavity
where the tumor lies (e.g., anus can be the point
of entry of the device so as to not perform
incision on the patient). The implanted device
will deliver radiation on the site.
o The approach must be local or localized to the
area where the tumor is because radiation is
also a predisposing factor to the development of
cancer.
SURGICAL MANAGEMENT
 Primary treatment for most Colorectal CA
 Maybe curative or palliative
o If diagnosed early, cure is possible. If not,
palliative care may be given to the patient (e.g.,
reducing the pain from obstructions).
TYPES OF SURGERIES:
 Depends on the location of the tumor.
 If the cancer is brought about by a massive metastasis, cancer is
already unresectable, and cannot proceed to surgery anymore.
Laparoscopic Colotomy w/ Polypectomy
Segmental resection w/ anastomosis
7
  The doctor should do mapping properly.
Permanent colostomy or ileostomy Nurses help with mapping by assisting the
doctor with identifying the proper stoma
Creation of a coloanal reservoir/Colonic J pouch site. (doctor to nurse: “sa tingin mo okay na
o Procedure includes creating a temporary loop in dito?”)
the ileostomy. It will be constructed to divert the  Thus, nurses should be aware of the proper
intestinal flow. We do anastomosis of the J stoma locations especially for pregnant and
pouch to the anal area fat patients
o 10-15 cm of the colon is used (this may vary per  Commonly, fat/obese patients are affected
agency policy) with this disease
o After 3 months, reversal of ileostomy is usually
done. Intestinal continuity is restored. This is
why we preserve anal sphincter during the ADDITIONAL INFO ABOUT PARKINSON’S DISEASE:
creation of colonal reservoir, because we want
to maintain its function once reversal is done. Some articles say that tobacco smoking is actually giving a protection
o This procedure helps in preserving the anal to a patient not to develop or having a lower risk of developing Parkinson’s
sphincter to retain its functions after the Disease. However, in a general advice we don’t advice the patient na mag-
operation smoke para ‘di kayo magparkinsons disease. Smoking gives protection,
‘yung nicotine raw para ‘di ka magkaroon ng Parkinsons Disease pero it
is not advisable since we are still going to weigh the risk and benefits of
TYPES OF COLOSTOMIES the smoking including the consumption of cocaine also gives you a
protection to develop PD but in a certain limit, but that particular research
ASCENDING COLOSTOMY
is still ongoing para mapatunayan pa ‘yung claim before the International
o Stoma is placed on the right area of the community of medicine accepts it.
abdomen
o BOARD EXAM QUESTION: Stool / fecal
material that is drained from the ascending colon
(right) is WATERY.
o
TRANSVERSE (DOUBLE – BARRELED) COLOSTOMY
o Stoma is placed on the right or left abdomen
o Right stoma from the transverse colon aka
Proximal stoma drains SEMIFORMED fecal
material
o Left stoma aka Distal stoma drains mucus
instead fecal material
o
TRANSVERSE LOOP COLOSTOMY
o This has two openings in the transverse colon
but only one stoma in the abdomen
o Intended for Inflammatory Bowel Diseases (IDB)
o
DESCENDING AND SIGMOID COLOSTOMY
o Stoma is on the left side of the abdomen
o Stool consistency is FORMED (hard and dry)
o Pre-Colostomy Procedure: MAPPING
 Do not allow the doctor to use the area near
the navel (pusod). This area has increased
skinfolds which stretches/pulls the colon
during change of positions (e.g. standing,
sitting).

o (line: wag papayag na diyan. Yung gitna yung

pusod)
o
 If the stoma is placed on the skinfold, it may
descend/revert inside
 This also increases the risk of infection
because sweat and bacteria accumulate in
the skinfold