Patients with Noninflammatory Intestinal

Disorders
UPNS 232 Adult Health and Illness
Intestinal Obstruction
• A blockage that completely stops or seriously impairs the passage of
intestinal contents
Types:
Mechanical: physical blockage of the intestines
• i.e. something is in the way such as:
• Adhesions (scar-like tissue)
• Tumor
• gallstones
• Hernias
• Fecal impaction
• Inflammation (Crohn’s; radiation therapy)
• Volvulus – twisting of the intestine
• Intussusception – telescoping
• Fibrosis r/t endometriosis
Intestinal Obstruction
Non-mechanical
• peristalsis is absent
• Post-operative ileus (POI)
• Intestinal function is lost for a few
hours or days
• Hypokalemia—predisposition for POI
• Peritonitis
• Intestinal ischemia
• Bowel infarction
• Medications
Assessment
History
• Ask patient about h/o GI disorders, surgeries & treatments
• N/V
• Color of emesis (green, bilious or hematemesis)
• Pain
• Noted fever
• Positive or negative flatus
• Character/color of stool (any blood in stool)
• Family h/o of colorectal cancer
• Patient is kept NPO with suspected obstruction
The Scoop on Poop
• Educate patients to inspect their
stool after every BM
• Color
• Consistency
• Frequency

• Large variances from day-to-day

could be based on:
• Food ingested
• Concerning GI tract issues
• Medications
 Assessment
• Physical
• Vital signs
• tachycardia, hypotension, fever
• Abdominal guarding or rigidity
Mechanical small intestine obstruction
• Mid-abdominal pain or cramping; sporadic
• Strangulation: localized steady pain
• Vomiting with obstruction
• Bile, mucus or orange-brown & foul smelling
(bacterial growth)—most common in proximal
small intestine
• Complete obstruction = Obstipation – no passage of
stool or flatus
• Partial obstruction = diarrhea
 Assessment
• Physical (continued)
Mechanical colonic obstruction
• Mild, intermittent colicky pain
• Low abdominal distention & obstipation
• Ribbon-like stools with partial obstruction
• + blood in stools
• Cancer or diverticulitis
• Peristaltic waves
• High pitched bowel sounds upon auscultation
(borborygmi) early in obstruction
• Late obstruction – absent bowel sounds
 Physical

Non-mechanical obstruction

• Constant diffuse pain

Assessment • Severe with vascular insufficiency or
infarction
• + abdominal distention
• ↓ bowel sounds or absent
• Emesis - + gastric content & bile
• Emesis rarely with foul odor
• May or may not have obstipation
 CT scan or MRI
• Small Intestine Obstruction
• Fluid and gas in small intestine &
absence of gas in colon
Abdominal US
• Evaluate cause of obstruction

Diagnosis Endoscopy (sigmoidoscopy or

colonoscopy)
• Determine cause of obstruction
• But not when perforation or
complete obstruction is
suspected
Labs
Planning and
Implementation
Goal: uncover and relieve obstruction
• Surgical or non-surgical methods
• Nonsurgical interventions:
• Partial obstruction with no evidence of
strangulation
• Paralytic ileus: good response to nonsurgical
methods
• Treatment of terminal colon cancer & bowel
obstruction
• NPO with NGT – to LCS
• Decompress the bowel and evacuate fluid &
air
• Monitor NG for proper functioning & placement
 Planning and
Implementation
• IVFs – all patients with an obstruction
• Patient is NPO
• F&E is lost particularly K+ via emesis and NG
suction
• IVF with K+ added (isotonic solution – NSS or
LR)
• Assess older patients carefully for fluid overload
• Monitor lung sounds, weight, I/O – daily
• Blood transfusion – for strangulated obstruction
• Blood loss into bowel or peritoneal cavity
• Monitor VS; skin turgor and mucous membranes
• Potential parenteral nutrition based on nutrition
status & length of NPO
Planning and Implementation
• Comfort ⇢ HOB elevated 30o
• Pain associated with abdominal distention
• Assess location and quality of pain
• Report any significant increase or change in type of pain
• Could mean perforation or peritonitis
• Opioids may be initially withheld until patient w/u completed
• N/V
• Signs of worsening obstruction or NG malfunction
• SE of morphine (slows GI motility)
• Dry mucous membranes and feeling of thirst
Surgical Management
• Patients with complete mechanical obstruction
• Strangulated obstruction
• Exploratory laparotomy
• Exploration of obstruction and cause
• Specific surgical interventions are based on the obstruction
• Adhesions: lysed
• Tumor or diverticulitis: colon resection with primary anastomosis
• Temporary or permanent colostomy
• Embolectomy or thrombectomy (for infarctions)
• Colectomy
Postoperative Management
• Open surgical procedure (not MIS)
• Continue with NG until peristalsis resumes
• Clear liquid diet once NG has been removed
• Continue IVF management
• Incision care and monitoring as per protocol
• Home Care
• Depends of management of obstruction (surgery vs. no surgery)
• Management of incision and/or possible colostomy
• Advice patient/family to report N/V or abdominal distention
• Pain medication management at home; stool softeners
 Polyps
• Growths in lining of large intestine
• Benign (hyperplastic) or indicative of
possible colon cancer (adenoma)
• Mainly asymptomatic but can cause:
• Bleeding; intestinal obstruction;
intussusception; abdominal pain
• Management
• Biopsy and polypectomy via
sigmoidoscopy or colonoscopy
• Patients with h/o familial adenomatous
polyposis (FAP) may require colectomy
(removal of colon)
Colorectal
Cancer
 CRC
• Cancer of rectum or colon
• Most are adenocarcinoma – arising from
a gland in the epithelial layer of colon
• Stages 0 to IV – based on tissue depth
and spread (metastasis)
• Begins as benign polyps in the early
stages
• Left untreated can lead to risk of
malignancy
• Most common site of CRC is the recto-
sigmoidal region
Risk Factors
• Adenomatous colon polyps
• Older than 50-years-of-age
• African-American
• Family history of colon cancer
• Inflammatory bowel disease (ulcerative colitis; Crohn’s disease)
• High-fat, low-fiber diet
• Long-term smoking/ETOH use
• Sedentary lifestyle
• h/o Helicobacter pylori; streptococcus bovis; Joh Cunningham (JC)
virus and HPV
Health Promotion
• Diet rich in calcium
• Calcium binds to free-fatty acids and bile salts in the lower GI tract
• Diet low in fat and simple carbohydrates; high in fiber
• Regular colorectal cancer screening
• Yearly fecal occult blood testing/colonoscopy every 10 years (average risk)
• Genetic testing for familial adenomatous polyposis and hereditary
nonpolyposis colorectal cancer
• Engaging in healthy lifestyle including regular physical exercise
• No smoking or excessive alcohol use
Assessment
Ask patient about….
• Changes in stool consistency or shape
• Blood in stool
• Left-sided tumors are more likely to produce frank bleeding &
change in bowel pattern
• Right-sided tumors cause stools to be darker due to ulceration of
colon
• Cramps or gas
• Does the patient have a palpable mass/abdominal distention/pain
• Any abnormal bowel sounds – high pitch indicate obstruction
• Weight loss and fatigue
• Vomiting
Early Detection: 2021 guidelines
Diagnostic Procedures
• Screening guidelines for individuals with polyps or a family history of
CRC (see previous slide “2021 guidelines”)
• Should be initiated at an earlier age and more frequent
• Fecal occult blood testing (FOBT)
• Two + stools within 3 days
• Stool from DRE should not be used – avoid false-positive
• Patient should avoid red meat, anti-inflammatory medications 48 hours before
testing
• Negative results do not completely rule out CRC
• Annual FOBT for clients ages 45 to 75
Diagnostic Procedures
• CT or MRI
• Visualization of lesions & metastases
• Endoscopy: colonoscopy,
sigmoidoscopy
• Visualization of lesions
• Biopsy for definitive diagnosis
• Recommended beginning at age 50
for average risk individuals, every 10
years
• Barium enema
• Visualization and location of tumor
• CBC – decreased H&H
• CEA – positive denotes malignancy
Nonsurgical Management
• Radiation therapy
• Given in conjunction with chemotherapy
• Palliative to control pain, hemorrhage, bowel obstruction or metastatic
disease
• Radiation alone pre or post surgery has not proven very effective

• Chemotherapy
• Post surgery for stage II or III
Surgical Management
• Type of surgical management is determined by:
• Tumor size and metastasis
• Patient condition
• Condition of bowel (not perforated or obstructed)
• Number of lymph node involvement determines prognosis
• Colon resection (colectomy)
• Removal of a portion of the colon to excise the tumor
• Open or MIS
• Remaining colon is reconnected (end-to-end) anastomosis or a colostomy or
ileostomy/ileoanal pull through (temporary or permanent)
• Abdominoperineal (AP) resection
 Surgical Management
• Ileoanal anastomosis
• Large intestine is bypassed
and the lower portion of
the small intestine is
directly attached to the
anal canal (ileal pouch-
anal anastomosis)
Surgical Management
• Pre-op
• Patient advised of possible colostomy or ileostomy
• If colostomy is anticipated CWOCN is consulted
• For placement of stoma (marks optimal area for the surgeon)
• Teaches patient/family rationale for ostomy formation
• Teaches patient/family about ostomy supplies and how
to change appliance
• Pain management
 Colostomy/Ileostomy

stools from colostomy - stools from Ileostomy -

soft or solid usually fluid
Postoperative Care
• NGT to LCS
• Removed with determined peristalsis and +
flatus
• Diet slowly progressed from liquids to solids
as tolerated
• Assess for any N/V
• IVFs
• IV PCA
• Teach patient regarding use of PCA
• Colostomy management
• Stoma should be reddish-pink, moist, small
amount of blood directly post-op, slight
edema
• Report a stoma that appears, pale, necrotic
(ischemia) or frank bleeding
Abdominoperineal (AP)
Resection

Removal of anus, rectum and

sigmoid colon
Psychosocial
• Provide ostomy teaching when patient is ready
• Management of ostomy may be more difficult for an older patient due to
impaired vision and decline in fine motor skills
• Alterations in body image and body function
• Assist patient and family with expression of feelings
• Assess coping skills
• Collaborate with social work and/or spiritual care to assist with coping
strategies
• Support groups
• American Cancer Society
• United Ostomy Association (https://www.ostomy.org/ )
Herniation
• Bowel herniation:
• Displacement of the bowel through a weakness of the abdominal muscle into
other areas of the abdominal cavity
• Incisional hernia:
• Postsurgical complication due to inadequate healing of the incisional site from
malnutrition, infection or obesity
• Strangulated hernia:
• Blood supply is cut off to a portion of the bowel increasing the risk for
obstruction, necrosis and perforation
• Abdominal distention, tachycardia, vomiting and abdominal pain
• Surgical intervention necessary
Strangulated Hernia
 • Caused by inflammation, surgical procedures, injury to
Malabsorption lining of intestine, prolonged use of antibiotics, bacterial
infections, or intrinsic disease
Syndrome
• Limited absorption of nutrients in the small intestine
Assessment
• Chronic diarrhea
• Due to unabsorbed nutrients
• Steatorrhea (large amounts of fat in stool)
• Weight loss
• Bloating & gas (carbohydrates)
• Light colored foul smelling stools (fats)
• Anemia (folic acid or vitamin B12
deficiencies)
• Bone pain (calcium and vitamin D
deficiency)
• Edema from hypoproteinemia
Diagnosis
• Fecal fat analysis
• Elevated
• Lactose tolerance test
• Determines inability to digest foods and beverages that contain lactose
• Hydrogen breath test
• Schilling test
• Urinary excretion of vitamin B12 (diagnosis of pernicious anemia)
• US
• Assess for pancreatic tumors and tumors in the small intestine
Interventions
• Avoid triggering substances (lactose)
• Low fat diet with severe steatorrhea
• Supplements
• Water-soluble vitamins such as folic acid and
Vitamin B
• Vitamins A, D and K
• Mineral – calcium, iron and magnesium
• Pancreatic enzymes
• Antibiotics for bacterial involvement
• Antidiarrheals
• IVF replacement associated with fluid
loss from diarrhea
 • Ignatavicius, D.D., Workman, M.L., and
Rebar, C.R. (2018). Medical-Surgical
References Nursing: Concept for interprofessional
collaborative care. St. Louis, MO: Elsevier