A.

MANAGEMENT OF PATIENTS
WITH LOWER
GASTROINTESTINAL DISORDERS
Diarrhea
Increased in frequency of bowel movement, increased
in amount of stool, and altered consistency of stool.
Associated with urgency, peri anal discomfort,
incontinence or combination of the 3.
Secondary to increased intestinal secretions, decrease
mucosal absorption, and altered motility.
IBS , IBD and lactose intolerance are frequent
underlying disease processes that cause diarrhea.
Certain medications , tube feeding formulas,
metabolic and endocrine disorders and viral or
bacterial infections may cause diarrhea.
Types of diarrhea
Secretory- high volume diarrhea caused by increased production and
secretion of water and electrolytes by intestinal mucosa
Osmotic- occurs when water is pulled into the intestines by the osmotic
pressure of unabsorbed particles , slowing the reabsorption of water.
Mixed- caused by increased peristalsis, combination of increased
secretion and decreased absorption in the bowel.
Clinical manifestations
Abdominal cramps
Distention
Intestinal rumbling
Anorexia
Thirst
Painful spasmodic contractions of the anus
Tenesmus
Watery stool, semi solid or greasy stool
Complications
Fluid electrolyte loss- may show:
 cardiac dysrhythmia
 Muscle weakness
 Paresthesia
 Hypotension
 Anorexia
 Drowsiness
Medical management
Treat the cause, control symptoms and prevent complications.
Antibiotic and anti inflammatory agents may reduce severity.
Nursing Care
Assess and monitor characteristics and pattern of diarrhea.
Bed rest and increase fluid during acute phase.
Low bulk diet, bland diet of semisolid and solid foods if
foods are tolerated y patient.
Avoid caffeine, carbonated drinks, very hot or very called
foods.
Restrict milk and milk products, fat, whole grain products,
fresh fruits, and vegetables for several days.
Administer medications as prescribed.
Rehydrate patient especially elderly.
Monitor serum electrolyte levels .
IRRITABLE BOWEL SYNDROME(IBS)
Functional disorder of intestinal motility.
Occurs more in women than in men.
No anatomic or biochemical abnormalities have been
found
Factors associated with IBS are :
 Heredity
 Stress
 High fat diet, irritating foods
 Alcohol consumption
 smoking
IRRITABLE BOWEL SYNDROME(IBS
Manifestations:
Altered bowel pattern
Pain
Bloating
Abdominal distention
Diagnostic test:
Stool studies
Contrast X-ray
Proctoscopy
Barium enema and colonoscopy
IRRITABLE BOWEL SYNDROME(IBS
Medical Management
Goals are to relieve pain, control diarrhea or
constipation, and reduce stress.
A healthy, high fiber diet to help correct constipation
and diarrhea
Exercise to reduce anxiety
Antidiarrheals and hydrophilic colloids maybe
prescribed.
Antidepressants for anxiety and depression.
Anticholinergics and Ca channel blockers to reduce
muscle spasm, cramps and constipation.
Nursing care
Teach patient and family on good dietary habits.
Avoid taking fluids together with meals to avoid distention.
Avoid alcohol and smoking.
Acute Inflammatory Intestinal Disorders
APPENDICITIS
Inflammation of vermiform appendix
 
Etiology
Barium ingestion
Fecal mass or fecalith( hardened stool)
Stricture
Viral infection
APPENDICITIS
Clinical Manifestation
Periumbilical pain progress to right lower quadrant/
McBurney’s point ( halfway between the umbilicus and anterior
spine of the ileum)
(+) Rebound tenderness (Blumberg sign)
(+) Rovsing’s sign ( LLQ is palpated pain is felt in the RLQ)
Nausea and vomiting
Low Fever
Hematology shows increase WBC count
Psoas sign (lateral position with right hip flexion)
Constipation
Decreased or absent bowel sound
Sudden cessation of pain ( indicates rupture)
Appendicitis
 Diagnostic test
 1. Hematology shows increase WBC with elevation of
Neutrophils
 2. Abdominal x-ray shows rigid lower quadrant density
 Nursing Management
Monitor GI status and pain. Sudden cessation of pain indicates
rupture of appendix.
Monitor V/S and Intake and output to determine fluid volume.
If surgery done by spinal anesthesia, put the client flat in bed 6-
8 hours post op.
Maintain on NPO status until bowel sounds return.
Monitor dressings for drainage and incision for infection post
op to prevent complications
Ambulation could be done after 24 hours.
 Appendicitis
 Medical Management
Appendectomy to decrease the risk of complications (peritonitis, abscess
formation and portal pyephlebitis
No enema and laxative, may lead to perforation
Analgesic; meperidine (Demerol) or morphine. Analgesic is only
administered once the diagnosis is confirmed and the client is ready for
surgery.
 
Acute Inflammatory Intestinal Disorders
DIVERTICULAR DISEASE
Clinical Forms
 a. Diverticulosis – the intestinal mucosa that protrudes through the
muscular wall (diverticulum) is already multiple and without
inflammation.

 b. Diverticulitis – when food, feces, bacteria entered the diverticulum

produce an infection and inflammation that could lead the perforation,
hemorrhage, obstruction or abscess formation.
Diverticular Disease
Etiology

Unknown
Age: 40 to 60 and up most common
Low fiber diet
Chronic Constipation
Congenital weakening of the intestinal wall
Straining during constipation
Diverticular Disease
Clinical Manifestations

Change in bowel habits

( alternate constipation and diarrhea)
Anorexia
Bloody stool
( indicates hemorrhage of diverticula)
Bloating or abdominal distention
Fever
Increase WBC count
Lower left quadrant pain or midabdominal pain that radiates to the
back
Flatulence
Rectal bleeding
Diverticular Disease
Medical Management
During acute diverticulitis: Hospitalization is required.
Broad spectrum antibiotic given and Demerol for pain. NO
Morphine because it cause constipation and increase
intraluminal pressure. Increase OFI and low fiber diet until
infection subside.
Antispasmodics: Propantheline (ProBanthine), Buscopan
(hyoscine N butyl bromide).
Bulk preparation: Docusate (Colace), psyllium (Metamucil)
to reduce bowel bacterial flora and increase fecal mass.
Surgical Management: Colon resection and candidate for
“double-barrel” temporary colostomy.
Monitor stools for occult blood to detect bleeding.
Double Barrel Colostomy
Diverticular Disease
Nursing Management
Assess abdominal distention and bowel sounds to
determine baseline and detect changes in patient’ s
condition.
Increase OFI 2L/day and increase bulk in diet.
Encourage exercise to improve abdominal tone.
Keep client is semi fowlers position to promote comfort
and GI emptying.
Monitor V/S, I and O and lab studies to assess fluid
status.
Administer analgesic (Demerol) and antispasmodic
agent to decrease intestinal spasm.
Diverticular Disease
Post op care:
 Watch for signs of infection, meticulous wound care, post op
bleeding,
Coughing and deep breathing exercise.
 Teach ostomy self care to promote healing and prevent complication.
Administer TPN if unable to tolerate enteral feeding.
Monitor for signs of complication: Perforation and peritonitis.
 Increase abdominal pain and tenderness.
 Abdominal rigidity
 ↑ WBC count
 ↑ ESR
 Fever
 Tachycardia and hypotension
INFLAMMATORY BOWEL DISEASE

2 Pathologic Conditions

 A. Regional Enteritis (Crohn’s Disease)

 B. Ulcerative colitis
REGIONAL ENTERITIS (CROHN’S DISEASE)
A non specific chronic inflammatory disease of small intestine usually
affecting the terminal ileum.
It may also affect large intestine, usually the ascending colon.
It’s slowly progressive with exacerbation and remission.
REGIONAL ENTERITIS (CROHN’S DISEASE)
Etiology;
Familial History
Autoimmune
Idiopathic (Unknown)
Risk Factors:
Smoking
Diet high in sugar and saturated fats, low in fruits and vegetables
Living in industrialized countries
REGIONAL ENTERITIS (CROHN’S DISEASE)
Clinical Manifestations
Right Lower Quadrant pain and spasms after eating
Chronic Diarrhea
Fever; Increase WBC
Steatorrhea ; Flatulence
Weight loss, malnutrition, anemia; Evidence of
nutritional deficiencies
REGIONAL ENTERITIS (CROHN’S DISEASE
Diagnostic Tests
(+) occult blood and steatorhea
Proctosigmoidoscopy – reveals inflammation of mucosal layer
Barium study of Upper GI – most conclusive diagnostic exam. Reveals “
string sign” segment of stricture separated by normal bowel. It also show
cluster of ulcers with “Cobble stone” appearance
Colonoscopy and endoscopy is performed to confirm the diagnosis
REGIONAL ENTERITIS (CROHN’S DISEASE)
REGIONAL ENTERITIS (CROHN’S DISEASE
 Nursing Management
Assess GI status and monitor fluid and electrolyte balance
Monitor V/S, I and O, Lab studies and daily weight.
Monitor the number, amount, and character of the stool to
detect deterioration of the GI status.
Administer TPN as ordered to rest the bowel and promote
nutritional status.
If client can tolerate oral feedings; small frequent meals diet
high in protein, high calories. Low in fat, fiber and residue
with bland foods. Intake of milk and gas forming foods is
restricted.
Provide skin and perianal care to prevent skin breakdown.
Prepare the client for surgery if needed.
REGIONAL ENTERITIS (CROHN’S DISEASE
Medical Management
Colectomy with ileostomy
TPN to rest the bowel
Pharmacologic Management:
Analgesic: Morphine or Demerol
Antibiotics: Metronidazole ( Flagyl), Sulfasalazine
(Azulfidine)
Antidiarrheal: Diphenoxylate (Lomotil)
Anti inflammatory: Prednisone (Deltasone)
Potassium supplements: potassium chloride ( K-LOr) usually
given with food
 
ULCERATIVE COLITIS
Is a specific, recurrent ulcerative and inflammation of the
mucosal and submucosal layer of the colon and rectum.

Etiology
Genetics
Idiopathic cause
Autoimmune disease
Emotional Stress
Viral and bacterial infections
ULCERATIVE COLITIS
ULCERATIVE COLITIS
Clinical Manifestations
Left lower quadrant pain
Diarrhea
Bloody, purulent, mucoid watery stools (15-20 times per day)
Hyperactive bowel sounds
Intermittent tenesmus
Rectal bleeding
Weight loss
Anorexia
Fever
Vomiting
Hypocalcemia and anemia frequently develop
ULCERATIVE COLITIS
Diagnostic Test
Hematology: ↓Hgb, ↓ Hct 2º to bleeding
Electrolyte panel: imbalance
(+) blood in the stool
Increase urine specific gravity
Barium enema – shows ulceration, mucosal
irregularities, focal strictures or fistulas, shortening of
the colon and dilation of bowel loops.
Colonoscopy and sigmoidoscopy – reveals hyperemia,
ulceration and inflamed mucosa with exudates
ULCERATIVE COLITIS
Nursing Management
Assess GI status, monitor fluid and electrolyte balance
to determine deficient fluid volume
Monitor V/S, I and O, Lab studies, daily weight, urine
specific gravity, calorie count and fecal count.
Monitor the number, amount, and character of the
stool to determine status of nutrient absorption
Administer IV fluids and TPN as ordered to rest the
bowel and promote nutritional status.
Nursing Care
If client can tolerate oral feedings; small frequent meals diet high in
protein, high calories. Low in fat, fiber and residue with bland foods.
Intake of milk and gas forming foods is restricted.
Semi – fowlers position to promote comfort
Provide skin care, mouth, nares and perianal care to promote comfort and
skin breakdown.
Prepare the client for surgery if needed.
ULCERATIVE COLITIS
Medical Management
Colectomy or pouch ileostomy
TPN to temporary rest the GI tract
Blood transfusion
Pharmacologic Management
Analgesic: Demerol
Hematenics: Ferrous sulfate
Antibiotics: Sulfasalazine (Azulfidine)
Antidiarrheal: Diphenoxylate (Lomotil), Loperamide (Imodium)
Anti inflammatory: Prednisone (Deltasone)
Potassium supplements: potassium chloride ( K-LOr) usually given
with food
Immunosuppresant: azathioprine (Imuran), cyclosphamide (Cytoxan)
Sedative: Lorazepam ( Ativan)
Complications
Toxic megacolon
Perforation
Bleeding due to ulceration
Vascular engorgement
Osteoporotic fractures
Clinical manifestations
Crampy pain
Passage of blood and mucus but no fecal matter or flatus
Vomiting
Extreme vigorous peristalsis
s/sx of dehydration
Distended abdomen
Hypovolemic shock
INTESTINAL OBSTRUCTION
Types:
Mechanical- the obstruction is due to the pressure on the intestinal walls
by: intussusceptions, tumors, stenosis, strictures,, adhesions, hernias and
abscess.
Functional- intestinal musculature cannot propel the contents along the
bowel. Ex. Muscular dystrophy, amyloidosis, endocrine disorder such as
DM, neurologic disorders.
Mechanical causes of Intestinal
obstructions
Adhesion- loops of intestines are adherent to areas
that heal slowly or scar after abdominal surgery.
Intussusception- one part of the intestines slips into
another part located below it ( like a telescope
shortening)
Volvulus – bowel twists and turn on itself.
Hernia- protrusion of intestine through a weakened
area in the abdominal muscle or wall .
Tumor- a tumor that exists within the wall of the
intestines extends into the intestinal lumen.
Clinical manifestations
Crampy pain
Passage of blood and mucus but no fecal matter or flatus
Vomiting
Extreme vigorous peristalsis
s/sx of dehydration
Distended abdomen
Hypovolemic shock
Diagnostic Tests
Abdominal x-ray studies
Laboratory studies ( CBC, electrolyte determination)
Medical management
Decompression thru NGT or small bowel tube
Surgical intervention for strangulation
Intravenous therapy to replace depleted water, Na, Cl, and K.
Nursing Care for patient with NGT
Nursing Care for patient with NGT
Explain the purposes of NGT insertion:
to decompress the stomach and remove gas and
fluid
To lavage and remove ingested toxin
To diagnose disorders of the GIT
To administer medications and feedings
To treat an obstruction
To compress bleeding site
To aspirate gastric contents for analysis
Nursing Care for patient with NGT
Describe to patient the expected sensations during tube insertion.
Assists during the insertion of the tube
Confirm the tube placement.
Monitor the patient’s reaction to the procedure and ,maintain its
function.
Provide oral and nasal hygiene and care.
Monitor for potential complications.
Remove the tube as ordered.
Nursing Management
Maintain the function of NGT , assess its output.
Monitor fluid and electrolyte balance , nutritional status and if symptoms
are improving.
Reports any complains of pain, abdominal distention and tenderness,
passage of stool or flatus.
Prepare patient for surgery.
Nursing Care of patient with Gastrostomy
Nursing Care of patient with Gastrostomy
After surgery patient is given tap water and 10 % glucose , 30-60ml, and is
increased gradually per day.
Water and milk can be given after 24 hours for permanent gastrostomy.
Blenderized foods are added gradually.
Provide tube care and prevent infection.
Verifies tube placement and assesses residuals and rotate the tube once
daily to prevent skin breakdown.
Clean the surrounding skin using water and soap daily and keep it dry.
COLORECTAL CANCER
Tumors of the colon and rectum and the third
common site of new cancer cases.
Etiology is unknown but risk factors are:
85 y/o and above
History of colon cancer
History of IBD
High-fat , high protein( high beef) low-fiber diet
Genital or breast cancer
Most are adenocarcinoma
Clinical manifestations
Symptoms are determined by its location, stage of disease and function of
the affected segment.
Most common is change in bowel pattern
Blood in the stool
Unexplained anemia
Anorexia, weight loss, fatigue
Dull abdominal pain( right sided lesion)
Melena
Distention and signs of obstruction( left sided lesion)
Diagnostic Tests
Abdominal and rectal exams
Fecal occult blood , Barium enema, proctosigmoidoscopy, and
colonoscopy
CEA ( CARCINOEMBRYONIC ANTIGEN)- secreted by lesion but not
highly reliable
Medical management
IVF and NGT suction for obstruction.
Blood transfusion for cases of bleeding.
Surgical removal of tumor ( maybe curative or palliative)
Adjuvant therapy- chemotherapy, radiation therapy, immunotherapy or
multimodality therapy.
Adjuvant Therapy
Dukes’ class C colon cancer- 5-fluorouracil plus levamisole regimen
Dukes’ class B or C rectal Ca- 5- fluorouracil and high doses of pelvic
irradiation.
Radiation is used before, during and after surgery to shrink the tumor, to
achieve better result and reduce recurrence.
Nursing Care
PRE-OPERATIVE NURSING CARE
Offer high calorie, protein and carbohydrate diet and low residue for several
days prior to surgery.
Full liquid diet 24-48 hours before surgery to decrease bulk.
Cleanse bowel by use of the prescribed laxatives, enema, or colonic
irrigation the night and in the morning before surgery.
Monitor food and fluid intake and output.
PRE-OPERATIVE NURSING CARE

NGT maybe placed to drain accumulated fluids and

prevent abdominal distention.
Assess for s/ s of obstruction and perforation.
Monitor fluid and electrolyte.
All procedure must be explained to the patient in the
language he/she can understand.
Provide emotional support to reduce anxiety.
POST OPERATIVE NURSING CARE
Provide wound care and detect s/ sx of hemorrhage.
Splint the incision site during coughing and DBE
Monitors v/s to monitor s/sx of infection.
If there is colostomy, examine the site for swelling , color of discharge, and
bleeding
Assess the bowel sounds, abdominal girth, and pain .
Determine any s/sx of pulmonary complications esp. For elderly patients.
CARE OF THE COLOSTOMY
CARE OF THE COLOSTOMY
It begins to function 3-6 days post surgery.
Provide skin care to prevent excoriation or ulceration of the site.
Secure the pouch with micropore during bathing.
Use mild soap, soft cloth and gentle wiping when cleaning the arae
around the stoma.
Cover the stoma with gauze while cleaning the site.
Dry the skin but do not rub the stoma and apply anti fungal cream.
Irrigate the stoma to empty the colon of gas, mucus and feces.