DISORDER OF LARGE

INTESTINE
Presented by
Deepika . R
M . Sc (N) I year
College of nursing
Madras medical college
• INTRODUCTION
• The large intestine is part of the digestive tract. 
• The large intestine is approximately 5 feet long, making up one-fifth of
the length of the gastrointestinal (GI) tract.
• The large intestine is responsible for processing indigestible food
material (chyme) after most nutrients are absorbed in the small
intestine.
• The large intestine is composed of 4 parts.
• It includes the cecum and ascending colon, transverse colon, descending
colon, and sigmoid colon.
• The large intestine performs an essential role by absorbing water,
vitamins, and electrolytes from waste material
• Function
• The large intestine has 3 primary functions:
• Absorbing water and electrolytes,
• Producing and absorbing vitamins, and
• Forming and propelling feces toward the rectum for elimination. 
• Mechanism
• Motility
• The intestinal wall is made up of multiple layers.
• The 4 layers of the large intestine from the lumen outward are the
• Mucosa,
• Submucosa,
• Muscular layer, and
• Serosa.
• CONT…
• The muscular layer is made up of 2 layers of smooth muscle,
• The inner, circular layer, and
• The outer, longitudinal layer.
• These layers contribute to the motility of the large intestine.
• There are 2 types of motility present in the colon,
• Haustral contraction and
• Mass movement. 
• Absorption of Water and Electrolytes
• Absorption of water occurs by osmosis.
• Water diffuses in response to an osmotic gradient established by the
absorption of electrolytes.
• Sodium is actively absorbed in the colon by sodium channels.
• Potassium is either absorbed or secreted depending on the concentration
in the lumen
• Production/Absorption of Vitamins
• The colon also plays a role in providing required vitamins through an
environment that is conducive for bacterial cultivation.
• Cont…
• The colon houses trillions of bacteria that protect our gut and produce
vitamins.
• The bacteria in the colon produce substantial amounts of vitamins by
fermentation.
• Vitamin k and b vitamins, including biotin, are produced by the colonic
bacteria.
• These vitamins are then absorbed into the blood.
• When dietary intake of these vitamins is low in an individual,
• The colon plays a significant role in minimizing vitamin disparity.
• The lower gastrointestinal (GI) tract includes the small and large
intestines
• from the duodenum to anus .The material that
• moves down the lower GI tract consists of food residues,
microorganisms,
• digestive secretions, and mucus. The mixture of these substances
• composes feces
• Disorders of the lower GI tract usually affect
• movement of feces toward the anus, absorption of water and
electrolytes,
• and elimination of dietary wastes.
• IRRITABLE BOWEL SYNDROME
• Irritable bowel syndrome (IBS) is a functional motility disorder
• primarily affecting the colon. It refers to a cluster of
• symptoms that occur despite the absence of an identifiable
• disease process.
• INCIDENCE
• It is estimated that one in five people in the United
• States have IBS (Mayo Clinic, 2008). Women are affected
• more often than men, which suggests a hormonal influence.
• IRRITABLE BOEWL SYNDROME
• In irritable bowel syndrome, the
spastic contractions
• of the bowel are visible in x-ray
contrast studies.
• Etiology
• The cause of IBS is unknown
• Hypersensitivity of the bowel wall that leads to disruption of the normal
function of the intestinal muscles.
• There is a familial predisposition.
• Stress, caffeine, and sensitivity to certain foods
• Dairy and wheat products seem to trigger IBS in some people.
 neuroendocrine dysregulation(due to any causes)

Fluctuating intestinal motility

Changes in motility

affects motor function in the GI

tract through neuron stimulation and inhibition,

parasympathetic neurotransmitter
• (e.g., acetylcholine) is released, intestinal motility increases
 Parasympathetic neuro transmitted
(E.G., Acetylcholine) is released

Intestinal motility increases

Diarrhea occur

An opposite effect occurs when the

smooth muscle of the gut

Responds to sympathetic neurotransmission

 Infection or irritation, as well as disturbances in vasculature
Of the bowel or metabolism
Signs and Symptoms
• . The three characteristics typical of this disorder are
• (1) alteration in bowel elimination (either constipation or diarrhea or both);
• (2) abdominal pain and bloating; and
• (3) the absence of detectable organic disease. The bloating and abdominal pain
usually have a sudden onset with production of flatus.
• The pattern of bowel dysfunction varies from case to case, and each patient seems to
have a unique pattern.
DIAGNOSTIC CRITERIA INCLUDE:
• Abdominal pain or discomfort that is:
• Relieved by defecation
• Associated with a change in stool frequency and/or consistency
• Other symptoms that support the diagnosis:
• Mucorrhea (mucus in the stool)
• Abdominal bloating
• Radiographic and endoscopic tests
common identification certain conditions
are,
• peptic ulcer disease, colorectal
• cancer, diverticulitis, or inflammatory
bowel disease
• barium enema and colonoscopy may
show
• the spasms, distention, and mucus
accumulations associated with IBS
• Diarrhea or Constipation
• Treatment and nursing management
• Medications for symptom control are prescribed according to the
patient's individual symptoms.
• Drugs that have been used include
• Bulk-forming agents,
• Antidiarrheals,
• Antispasmodics,
• Antidepressants,
• Anticholinergics/sedatives, and
• Mild analgesics to relieve discomfort
• Cont…
• A diet high in fiber also may be
prescribed. Bulk forming agents
such as Metamucil or stool
softeners may be recommended.
• Gas-forming foods such as legumes
and those in the cabbage family
should be avoided.
• Avoiding onions, potatoes,
cucumbers, coffee, tea, carbonated
beverages, and alcohol can be
helpful.
• Milk is restricted if the patient has
shown evidence of intolerance to it.
• AVOIDANCE OF FOOD ITEMS:
• Lactase tablets may be used for
lactase deficiency but are not
indicated if an allergic sensitivity is
present.
• Gluten intolerance has been
identified as a possible trigger for IBS
symptoms.
• Wearing loose clothing is more
comfortable if bloating or increased
abdominal pressure occurs.
• Give instruction about medications
and diet therapy.
• Data Collection for a Patient With
Suspected Irritable Bowel Syndrome
• For a patient with symptoms suggesting
IBS, gather the following data:
• History
• When symptoms first began
• Stool pattern: frequency, character of
stool
• Presence of bloating and flatus
• Incidence of pain or cramping; location,
duration, character
• Pain that awakens the patient at night
• Precipitating factors for cramping or diarrhea
• Known food intolerances
• Methods of self-treatment
• Known stressors
• Methods of coping with stress
• Physical Examination
• Presence and character of bowel sounds
• Degree of firmness and tenderness of abdomen
• Location of tenderness
• Appearance of stool
• Complementary and alternative
therapies
• Peppermint oil for the relief of
abdominal discomfort
• Peppermint oil may provide some
temporary relief of abdominal pain
for patients with IBS;
• However, those with
gastroesophageal reflux disease
(GERD) should avoid this alternative
therapy
• Because it can worsen heartburn
• Diverticula
• The term diverticulum refers to a
small, blind pouch resulting from a
protrusion of the mucous
• membranes of a hollow organ
through weakened areas of the
organ's muscular wall.
• When diverticula are present, the
patient is said to have
diverticulosis.
• INCIDENCE:
• The exact incidence of diverticulosis
is not known because most
diverticula are asymptomatic.
• It is uncommon in people younger
than 50 years and almost universal
in those older than 90 years.
• PATHOPHYSIOLOGY:
• Diverticulitis occurs when the
diverticula become inflamed or
infected and occurs in about 20% of
those affected by diverticulosis.
PATHOPHYSIOLOGY Diverticulitis

diverticula become inflamed or infected

Food particles accumulate in the diverticula

mix with the intestinal bacteria,

irritate the mucosal wall

The intestinal wall may become infected

• CONT…..
if it is not treated,

perforation and peritonitis may occur

FOR ESOPHAGEAL DIVERTICULA:
Herniation of esophageal mucosa

submucosa into
surrounding tissue.
The disorder is more common in older patients.
ESOPHAGEAL DIVERTICULUM
• SIGNS AND SYMPTOMS:
• Initially be asymptomatic
• Inflammation or infection
• Rectal bleeding.
• Diverticulitis of the Intestine produces
symptoms of diarrhea or constipation,
• Acute left lower abdominal pain,
• Bloating,
• nausea, and
• vomiting.
• Esophageal diverticula
• Produce symptoms of
• Dysphagia,
• Regurgitation,
• Nocturnal cough, and
• Halitosis (bad breath).
• There is a risk of esophageal perforation .
• CONT….
• COMPLICATION:
• Intestinal obstruction or
• By peritonitis if the intestinal wall ruptures.
If bleeding is massive, there will be
hypotension and
• eventual shock.
• DIAGNOSTIC EVALUTION:
• Computed tomography of the abdomen with
colonic contrast.
• Barium enema and
• colonoscopy should be avoided in acute cases
because of the risk of bowel perforation
• Dietary management:
• A high-fiber diet :
• breads and fruits such as
• Apples,
• Seedless berries,
• Peaches, and pears adds fiber.
• High-fiber - vegetables—squash,
broccoli, cabbage, and spinach—and
legumes, including dried beans, peas,
and lentils,
• Provide bulk that decreases constipation
and speeds intestinal transit time.
• Plenty of fluids helps regularity.
• Patients who have recurrent diverticulitis may be instructed to
• Avoid foods:
• Husks, such as peanuts, sunflower seeds, berries with seeds, tomatoes, and
popcorn, as a precaution;
• The husks may get into the diverticulum and irritate it, causing
• Inflammation and eventual diverticulitis.
• Medical management:
• managed conservatively.
• increased fluids and bulk
• laxatives, or stool softeners to control constipation may be all that are needed.
• For diverticulitis, antidiarrheal medication may be prescribed.
• stool softeners to control constipation
• For diverticulitis,
• antidiarrheal medication may be prescribed.
• Mild pain medication-abdominal discomfort in ambulatory patients.
• Outpatient treatment may include clear liquids for 2 to 3 days with oral
antibiotics.
• parenteral antibiotics with intravenous (IV) hydration and bowel rest
• Morphine is acceptable for pain management
• SURGICAL MANAGEMENT :
• surgical removal of the affected part of the colon.(colectomy)
• The Hartmann’s procedure for diverticulitis: primary
• resection for diverticulitis of the colon. The affected segment
• (clamp attached) has been divided at its distal end. In a
• primary anastomosis, the proximal margin (dotted line) is
transected
• and the bowel attached end to end. In a two-stage
procedure,
• a colostomy is constructed at the proximal margin with
• the distal stump oversewn (Hartmann procedure, as shown)
• and the stump is left in the pelvis. The distal stump may be
• brought to the surface as a mucous fistula if there is concern
• about blood supply. The second stage consists of colostomy
• takedown and anastomosis.
• INTESTINAL OBSTRUCTION
• Intestinal obstruction is a sudden or gradual blockage of the intestinal
tract that prevents the
• normal passage of GI contents through the intestines
• Etiology:
• Mechanical obstruction
• Nonmechanical obstruction
• Mechanical obstruction
• blockage of the lumen of the bowel. Examples include
• tumors,
• adhesions,
• CONT……
• strangulated hernia,
• twisting of the bowel (volvulus),
• telescoping of one part of the
• bowel into itself (intussusception),
• barium impaction,
• intestinal parasites, and
• Gallstones
• Abdominal adhesions are a common
cause of intestinal obstruction.
• Three causes of intestinal obstruction.
• A, Intussusception ; Invagination or shortening of
the colon caused by the movement of one
segment of bowel into another.
• B, Volvulus of the sigmoid colon; the twist is
counterclockwise in most cases. Note the
edematous bowel.
• C, Hernia (inguinal). The sac of the hernia is a
continuation of the peritoneum of the abdomen.
The hernial contents are intestine, omentum , or
other abdominal
• contents that pass through the hernial opening
into the hernial sac.
• Nonmechanical obstruction
• Absence of peristalsis.
• Paralytic ileus (failure of forward movement of bowel contents)
• After abdominal surgery, from infection, or as a consequence of
hypokalemia
• Secondary to intestinal thrombus.
• Infections can occur in some pelvic inflammatory diseases or
• Peritonitis,
• In uremia, and
• In heavy-metal poisoning.
• PATHOPHYSIOLOGY:
• Due Mechanical obstruction

• blockage of the lumen of the bowel.

• twisting of the bowel (volvulus), telescoping of one part of the

• bowel into itself (intussusception), barium impaction.

• Due to non-mechanical obstructive cause.

• Due to absence of peristalsis.

CONT…..
• Paralytic ileus

• obstruction/Infection occur.
• If fluid or gas accumulate in the intestine

• Increase intraluminal pressure.

• Cause severe pain.

• Signs and symptoms:
• According to the location of the obstruction
• High-pitched bowel sounds are heard above the point of obstruction,
• Sharp, brief pains in the upper abdomen.
• Bowel sounds are absent below the obstruction
• Other symptoms include
• vomiting,
• with rapid Dehydration and
• only slight abdominal distention.
• Frequent, high-pitched bowel sounds are heard above the point of
obstruction,
• CONT…..
• Intestinal obstruction in the upper
• Abdomen can cause respiratory difficulty
• Pains that last several minutes or longer and correspond to peristaltic
waves.
• Fecal odor or Material in the emesis suggests a complete intestinal
obstruction.
• Treatment
• Insertion of a nasogastric (NG) tube relieves symptoms by
decompressing or removing gas, intestinal contents and mucous.
• The long tube or miller- abbott tube has a balloon that is inflated after
passage into the pylorus
• Peristalsis, which is preserved above the blockage, moves the tube to
the point of blockage.
• Surgical management:
• Obstruction caused by adhesions, volvulus, hernia, or tumor.
• Adhesions are lysed (broken apart), a volvulus is untwisted
• Colectomy may be necessary if tumor is involved.
• Miller-Abbott intestinal tube used for
decompression. It is advanced
through the intestines
• to the prescribed point. The Miller-
Abbott tube has a double lumen and
is weighted with tungsten. 1,
• Portion of the metal tip leading to
the balloon. 2, Portion of the metal
tip leading to the lumen that can be
• suctioned. 3, Balloon inflated with
air.
• Nursing Management:
• Placing the patient in a fowler position helps relieve pressure and aids in
removing gas and
• Intestinal contents through the intestinal tube
• Fluid and electrolyte status must be monitored closely. Measure
abdominal girth every 2 to 4 hours by placing the tape at the same
location on the abdomen each time.
• Pain control is essential, but worsening pain may signal an unresolved,
• Intestinal obstruction that can lead to rupture of the intestine, peritonitis,
shock, and death.
• Inflammatory Bowel Disease
• Ulcerative Colitis and Crohn Disease
• Inflammatory bowel disease (IBD) includes both ulcerative colitis (UC)
and Crohn disease (regional
• ileitis). UC is an inflammation with formation of ulcers of the mucosa of
the colon.
• Crohn disease is a chronic inflammatory disease that can involve any
part of the GI tract but most commonly affects the distal ileum and
proximal colon.
• INCIDENCE:
• People with UC have a 40% higher incidence of some types of arthritis.
CROHN’S
DISEASE
• Etiology
• Both diseases are idiopathic, meaning the cause is not known
• Crohn disease and UC have a genetic predisposition
• UC is three times more common than Crohn
• disease.
• Pathophysiology
Due to unknown cause

UC and Crohn disease are immunologic responses

The end result is inflammation of the mucosal lining of the intestinal tract,
•
• causing ulceration, edema, bleeding, and
• fluid and electrolyte loss.

• The constant inflammation disrupts normal

• cell function, and cellular mutations may occur.
• Comparison of Ulcerative Colitis and Crohn Disease
ULCERATIVE COLITIS
Area affected Mucosa only; usually involves rectum
and proceeds up the colon.
Characteristic Mucosa is red; intestinal wall is
s edematous and friable, bleeding
easily;
pseudopolyps are present.
Signs and Diarrhea, frequently bloody;
symptoms abdominal cramping relieved by
defecation; rectal bleeding.
CROHN DISEASE
Full thickness of the intestine; most
common in small intestine.
Edematous bowel wall, inflammatory
cells, mucosal ulcerations, granulomas,
and “skip” lesions
Fever, malaise, fatigue, weight loss,
intermittent diarrhea, cramping or
steady right lower
quadrant or periumbilical pain,
postprandial bloating.
Complication Massive hemorrhage; hypovolemia, toxic Fistulas, anal fissures, perianal disease, bowel
megacolon (rapid dilation of obstruction or perforation
the intestines), cancer of the colon.
• Signs and Symptoms
• Patients with IBD have attacks of diarrhea that may be bloody and
contain mucus; abdominal
• pain with cramping; malaise; fever; and weight loss.
• Slow bleeding and oozing will show a black, tarry stool. If
• diarrhea is frequent, the blood may be more reddish.
• Others have serious intestinal
• hemorrhage with fluid and electrolyte imbalances.
• Opioids and Anticholinergic Medications
• opioid medications or anticholinergic medications should be
• avoided if there is fever, leukocytosis, or worsening symptoms because
these medications will further reduce the tone of the colon
• Diagnosis
• based on the patient's medical history and symptoms Colonoscopy,
flexible sigmoidoscopy, mucosal biopsy, barium enema, and stool analysis
may be
• performed to confirm the diagnosis.
• Treatment
• Treatment for UC and Crohn disease varies according to severity and
frequency of symptoms.
• administration of antidiarrheal drugs,
• Long term sulfasalazine therapy, and
• medications to relieve abdominal cramps.
• Budesonide (Entocort) is used to help control disease in the ileum.
Patients with
• advanced disease who are not surgical candidates may be given
azathioprine, 6-mercaptopurine,methotrexate, levamisole, or
cyclosporine to help control the disease
• Infliximab (Remicade), a monoclonal antibody against tumor necrosis
factor, has greater than 80% response rate for Crohn disease, but only
about a 50% success rate with UC.
• The drug is extremely expensive and is given IV by a set protocol.
• Certolizumab pegol (Cimzia) is a drug for
• patients with moderate to severe Crohn disease who have not
responded to conventional treatments.
• Corticosteroids are used for moderate to severe cases to decrease the
inflammation.
• During acute attacks, fluid replacement may be necessary.
• Blood transfusion are given when anemia is present. Oral 5-
aminosalicylic acid (5-ASA) derivatives, such as olsalazine sodium
(Dipentum), are useful for those patients who cannot tolerate
sulfasalazine.
• THE RECOMMENDED DIET:
consists of low-fat,
• low-fiber foods that are high in protein and calories.
• Small frequent feedings are best.
• Lactose avoidance helps some patients
• SURGICAL INTERVENTION:
• Proctocolectomy, and creating an ileostomy.
• A patient with uc may be a candidate for an ileal reservoir (kock pouch) or
an ileoanal
• Anastomosis rather than a standard ileostomy
• The patient uses a catheter to empty the reservoir after the Kock procedure
• Nursing Management
• Assessment (Data Collection)
• A complete health assessment is performed with particular attention to
nutritional, fluid, and
• electrolyte status. A thorough abdominal assessment is performed,
identifying pain location.
• Nursing diagnosis and planning
• Problem statements/nursing diagnoses might include:
• Acute or chronic pain due to intestinal inflammation.
• Fluid volume deficit due to diarrhea fluid loss.
• Implementation and evaluation
• For an acute attack of IBD, care includes monitoring the number and character of
stools, periodic
• Auscultation of bowel sounds, measurement of intake and output, and daily
weight measurement.
• Check for signs of internal bleeding and monitor laboratory data for evidence of
electrolyte
• Imbalances and anemia. Indicators of successful therapy include a decrease in
abdominal cramping
• And discomfort and return of typical bowel pattern.
• Risk Factors for Colorectal Cancer:
• Increasing age.
• Family history of colon cancer or polyps
• Previous colon cancer or adenomatous polyps
• High consumption of alcohol
• Cigarette smoking
• Obesity
• History of gastrectomy
• History of inflammatory bowel disease
• High-fat, high-protein (with high intake of beef), low-fiber diet
• Genital cancer ( eg , endometrial cancer, ovarian cancer) or
• Breast cancer (in women).
• Cancer of the Colon
• Cancer of the large intestine, also called colorectal cancer, is the third most
common malignancy in both men and women in the United States
• Approximately 93,090 colorectal cancer cases were expected to occur in
2015 (American Cancer Society, 2015).
• Colorectal cancer is one of the most preventable and curable of all cancers
if it is found in the early stages, and
• mortality rates have fallen over the last 30 years as detection has become
easier.
• Healthy People 2020
• objectives include the reduction of deaths by colorectal cancer and a
decrease in the incidence of
• invasive colorectal cancer.
• Colorectal cancer incidence
• Colorectal cancer incidence is highest in African American men and women.
Mortality rates in
• African Americans also are higher than in the white population. It is not
certain whether this is
• Because of limited access to health care or other reasons.
• Etiology
• The cause of colorectal cancer has not been established but is generally
believed to be a mutation of a naturally occurring process of colon tissue
repair and replacement. Other risk
• factors are smoking, alcohol consumption, physical inactivity, obesity, and a
diet high in saturated
• fat and/or red meat, as well as inadequate intake of fruits and vegetables
• Other risk factors are
• smoking,
• alcohol consumption,
• physical inactivity,
• obesity, and
• a diet high in saturated
• fat and/or red meat, as well as inadequate intake of fruits and vegetables
• The Colon and Conjugated Linoleic Acid
• In research studies with animals, conjugated linoleic acid (CLA) was found
to have a protective
• effect against inflammation-induced colon cancer
• PATHOPHYSIOLOGY:
• The cancerous tumor tissue may be polypoid, protruding into the bowel
lumen

• extend around the bowel, causing stricture.

• large bowel tumors are

• Adenocarcinomas

• The tumor may spread into adjacent structure or via the lymphatics
• or the bloodstream.
• Any change in bowel habits, either diarrhea or constipation, could be a
sign of colon cancer
• (American Cancer Society, 2015a).
• Other symptoms include red blood in the stool, black tarry stools,
change in stool shape
• (ribbonlike stool), abdominal distention without weight gain, sensation
of incomplete evacuation
• after a bowel movement, and anemia resulting from intestinal bleeding
• DIAGNOSIS:
• Screening tests include an annual stool guaiac test or fecal
immunochemical test or stool DNA test
• double contrast barium
• x-ray every 5 years, or CT colonography (virtual colonoscopy) every 5
years. Colonoscopy is
• recommended if any of the screening tests are positive (American
Cancer Society, 2015a). If
• adenomatous polyps are discovered early and removed, colon cancer
could be prevented
• Transrectal ultrasound may
• Be used to determine the extent of a small rectal lesion.
Carcinoembryonic antigen (CEA) is elevated
• In 70% of patients with colorectal cancer, but because it is nonspecific to
this type of cancer,
• Treatment:
• Treatment of colorectal cancer usually involves surgical removal of the
affected portion of the Intestine.
• Reconnection of the remaining intestine portions (anastomosis) is done
if the lesion is
• Most tumors are resected with an open approach, but laparoscopic surgery is
an option for a
• small, localized tumor.
• Colectomy or hemicolectomy.
• Colectomy is the removal of the diseased portion of the colon. The remaining
ends of the colon are
• reattached (anastomosed). Hemicolectomy is removal of one half of the colon.
• Abdominoperineal resection.
• Abdominal resection is performed for cancer in the rectum or low sigmoid
colon. It is a very
• extensive surgical procedure in which part of the colon and the entire rectum,
anus, and regional
• lymph nodes are removed.
• Examples of areas where cancer can occur,
the
• Area that is removed, and how the
anastomosis is performed
• Cecum and lower
• Ascending colon
• Descending colon
• And upper sigmoid
• Low sigmoid and
• Upper rectum
• Rectal sigmoid resection
• Staging of Colorectal Cancer:
• Dukes’ Classification–Modified Staging System
• Class A: Tumor limited to muscular mucosa and
• submucosa
• Class B1: Tumor extends into mucosa
• Class B2: Tumor extends through entire bowel wall into
• serosa or pericolic fat, no nodal involvement
• Class C1: Positive nodes, tumor is limited to bowel wall
• Class C2: Positive nodes, tumor extends through entire
• bowel wall
• CONT…..
• Class D: Advanced and metastasis to liver, lung, or bone
• Another staging system, the TNM (tumor, nodal involvement,
• metastasis) classification, may be used to describe
• the anatomic extent of the primary tumor, depending on:
• Size, invasion depth, and surface spread
• Extent of nodal involvement
• Presence or absence of metastasis
• The higher the score in each category, the worse the
• disease and prognosis.
• Diagnosis
• Nursing Diagnoses
• Based on the assessment data, the major nursing diagnoses
• May include the following:
• Imbalanced nutrition, less than body requirements , Related to nausea
and anorexia
• Risk for deficient fluid volume related to vomiting and Dehydration
• Anxiety related to impending surgery and the diagnosis Of cancer
• Risk for ineffective therapeutic regimen management
• Related to knowledge deficit concerning the diagnosis,
• The surgical procedure, and self-care after discharge
• CONT….
• Impaired skin integrity related to the surgical incisions (abdominal and
perianal), the formation of a stoma, and frequent fecal contamination
of peristomal skin
• Disturbed body image related to colostomy
• Ineffective sexuality patterns related to presence of ostomy and
changes in body image and self-concept
• Planning and Goals
• The major goals for the patient may include attainment of optimal level
of nutrition;
• Maintenance of fluid and electrolyte balance;
• Reduction of anxiety;
• Learning about the diagnosis, surgical procedure, and self-care after
discharge;
• Maintenance of optimal tissue healing;
• Protection of peristomal skin;
• Learning how to irrigate the colostomy
• Nursing Interventions
• Preparing the Patient for Surgery
• The patient awaiting surgery for colorectal cancer has many
• concerns, needs, and fears.
• Providing Emotional Support
• Patients anticipating bowel surgery for colorectal cancer
• may be very anxious. They may grieve about the diagnosis,
• the impending surgery, and possible permanent
• colostomy.
• Providing Postoperative Care
• Postoperative nursing care for patients undergoing colon resection
• or colostomy is similar to nursing care for any abdominal
• surgery patient (see Chapter 20), including pain
• management during the immediate postoperative period
• Maintaining Optimal Nutrition
• The nurse teaches all patients undergoing surgery for colorectal
• cancer about the health benefits to be derived
• from consuming a healthy diet.
• Providing Wound Care
• The nurse frequently examines the abdominal dressing during
• the first 24 hours after surgery to detect signs of hemorrhage.
• Monitoring and Managing Complications
• The patient is observed for signs and symptoms of complications.
• It is important to frequently assess the abdomen,
• including bowel sounds and abdominal girth, to detect
• bowel obstruction.
• Removing and Applying the Colostomy Appliance
• The colostomy begins to function 3 to 6 days after surgery.
• The nurse manages the colostomy and teaches the patient
• about its care until the patient can take over its management.
• Irrigating the Colostomy
• The purpose of irrigating a colostomy is to empty the colon
• of gas, mucus, and feces so that the patient can go about social
• and business activities without fear of fecal drainage.
• Supporting a Positive Body Image
• The patient is encouraged to verbalize feelings and concerns
• about altered body image and to discuss the surgery
• and the stoma (if one was created).
• Discussing Sexuality Issues
• The nurse encourages the patient to discuss feelings about
• sexuality and sexual function.
• Promoting Home and Community-Based Care
• TEACHING PATIENTS SELF-CARE. Patient education and
• discharge planning require the combined efforts of the
• physician, nurse, WOC nurse, social worker, and dietitian.
• Patients are given specific information, individualized
• to their needs, about ostomy care and signs and
• symptoms of potential complications.
• PLACEMENT OF PERMANENT
COLOSTOMIES. THE NATURE
• of the discharge varies with the site. Shaded
areas show sections
• of bowel removed. A, With a sigmoid
colostomy, the feces
• are formed. B, With a descending colostomy,
the feces are semi formed.
• C, With a transverse colostomy, the feces are
unformed.
• D, With an ascending colostomy, the feces
are fluid.
• Gastric Common
causes of
peritonitis . ulcer

• Appendicitis

• Duodenal ulcer

• Inflammatory
• bowel disease

• Diverticulitis
• of sigmoid