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Assessing Clients with Bowel Elimination Disorders

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Title: Assessing Clients with Bowel Elimination Disorders


1
Assessing Clients with Bowel Elimination Disorders
  • Chapter 26

2
Review of Anatomy and Physiology
  • Small intestine
  • pyloric sphincter to ileocecal junction
  • three regions
  • duodenum
  • jejunum
  • ileum
  • Function - chemical digestion and absorption
  • microvilli, villi and circular folds increase
    surface area

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4
Small bowel surgery
5
Small intestine
6
Review of Anatomy and Physiology
  • Large intestine - colon
  • ileocecal valve to anus
  • Cecum - first part of intestine - appendix
  • Colon divided into 3 parts
  • ascending
  • transverse
  • descending
  • Function - eliminate undigestible food, absorb
    water, salt and vitamins

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Large Intestine
9
Assessment of Bowel Function
  • Subjective
  • onset
  • characteristics
  • course
  • severity
  • precipitating factor
  • relieving factors
  • associated symptoms

10
Sample Interview Questions
  • Can you describe the type of cramping and
    abdominal pain you are having?
  • Have you every had bleeding from your rectum?
  • Have you noticed any changes in your bowel habits?

11
Assessing the Abdomen
  • Inspection, auscultation, percussion and
    palpation as described
  • Rectal exam - polyps
  • Stool for occult blood
  • requires further testing for colon CA or GI
    bleeding 2nd to peptic ulcers, ulcerative colitis
    or diverticulosis

12
Blood and Stool
  • Melena - black tarry stool
  • Blood on Stool - bleeding sigmoid colon, rectum
  • Blood in Stool - colon, ulcerative colitis,
  • diverticulitis, tumor, ulcer
  • Stool black, hard oral iron
  • Strong odor blood of high fat content
  • steatorrhea

13
Nursing Care of Clients with Bowel Disorders
  • Chapter 26

14
Disorders of Intestinal Motility
  • Diarrhea
  • serious in the young and elderly
  • increase in the frequency, volume and fluid
    content of the stool
  • Causes
  • bacteria, or parasitic infections, malaborption,
    medications, diseases, allergies or pyschological

15
Diarrhea
  • Clinical Manifestations
  • vary widely from several large watery stool to
    very frequent small stools
  • result in severe electrolyte imbalances
  • hypokalemia - Low K
  • hypomagnesemia - low Mg
  • hypovolemia - fluid volume deficit - hypovolemic
    shock with vascular collapse

16
Diarrhea
  • Collaborative Care
  • treat underlying cause
  • Labs
  • stool specimen - for WBCs, parasitic infections
    culture
  • electrolytes - imbalance
  • Diagnostic tests
  • sigmoidoscopy - direct exam of bowel

17
Diarrhea
  • Client prep
  • consent, npo, enemas
  • Dietary management
  • fluid replacement - gatorade, pedialyte
  • bowel rest for 24 hours - add milk last
  • Pharmacology
  • absorbents, anticholinergics, antibiotics

18
The Client with Constipation
  • The infrequent or difficult passage of stool
  • two or less BMs per week
  • affects elders - impaired health, medications,
    decrease physical activity
  • Diagnostics
  • Barium enema
  • - tumors, diverticular disease
  • colonoscopy
  • - tumor, obstruction, take bx

19
Constipation
  • Dietary Management
  • high fiber - vegetable fiber
  • adequate fluids
  • Pharmacology
  • laxatives for short term use
  • bulk form agents for long term use
  • enemas - acute short term or as prep

20
Irritable Bowel Syndrome
  • Disorder characterized by alternating periods of
    constipation and diarrhea
  • Cause - no organic cause found
  • related to food ingestion, meds., stress,
    hormones
  • looking at motor activity of the G.I. tract

21
IBS
  • Clinical Manifestations
  • Colic-like abdominal pain
  • Altered bowel elimination
  • mucous in stool, change in frequency, straining,
    urgency, incomplete emptying
  • Bloating, tenderness
  • Labs and Diagnostics
  • stool specimen, colonoscopy, UGI with SBFT
  • Dietary management
  • add fiber - adds bulk and water content

22
Bloating and Cramping
23
The Client with Fecal Incontinence
  • Loss of voluntary control of defecation
  • Causes
  • interfere with sensory or motor control of rectum
    and anal sphincters
  • neuro -spinal cord injury, head injury
  • local trauma - OB tears, anal-rectal injury,
    surgery
  • Other - radiation, impaction, tumors, confusion

24
Fecal Incontinence
  • Collaborative Care
  • dx made by history
  • digital exam - poor sphincter tone
  • treatment
  • bowel training program - establish regular
    pattern
  • dietary changes
  • stimulant - coffee, suppository, digital
    stimulation
  • surgery - colostomy

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Acute Inflammatory and Infectious Disorders
  • Appendicitis
  • inflammation of the appendix
  • common cause of acute abd pain
  • most common reason for emergency abd surgery
  • most common in adolescents and young adults

27
Appendicitis
  • Simple
  • appendix is inflamed but intact
  • Gangrenous
  • tissue necrosis and microscopic perforations
  • Perforated
  • gross perforation and contamination of peritoneal
    cavity

28
Appendicitis
  • Clinical Manifestations
  • continuous mild generalized upper abd pain
  • then intensifies and localizes to RLQ
  • rebound tenderness - tenderness on release of
    pressure at McBurneys point
  • Rt heel tap pain
  • What about pain medications?
  • nausea, anorexia, vomiting, low-grade fever
  • perforation - increased pain, temp, abscess

29
Appendicitis Pathophysiology
  • The appendix can become obstructed by fecalith
    (hard masses of feces) a stone, inflammation or
    parasites.
  • As a result of the obstruction the appendix
    becomes distended with fluid.
  • This increases pressure within the appendix and
    impairs its blood supply.
  • The lack of blood supply leads to inflammation,
    edema, ulceration, and infection of the tissue.
  • Can become necrotic and perforate if treatment is
    not indicated.

30
Appendicitis
  • Interdisciplinary Care
  • Labs - CBC, UA, pregnancy test
  • Diagnostic studies - abd X-ray, pelvic exam, ABD
    ultrasound
  • Pharmacology - IVs , antibiotics - third
    generation cephalosporin - rocephin
  • Surgery - Appendectomy - exploratory vs laproscopy

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32
The Client with Peritonitis
  • Inflammation of the peritoneum - is the most
    significant complication of acute abdominal
    disorders
  • perforation of appendix, diverticulum, peptic
    ulcer, pancreatitis or GSW
  • bacterial infection - E coli or klebsiella

33
Peritonitis
  • Clinical Manifestations
  • Abdominal Effects
  • Diffuse or localized pain - rebound
  • Boardlike rigidity
  • diminished or absent bs
  • distention, anorexia, nausea, vomiting
  • Systemic effects
  • fever, malaise, tachycardia, restlessness
  • shock

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35
Peritonitis
  • Labs and Diagnostics
  • CBC - WBCs with shift to the left, immature wbc
    out to help fight infection
  • Blood culture - bacterial invasion into blood
    stream
  • Paracentesis - obtain peritoneal fluid
  • Abd x-ray - free air under diaphragm indicative
    of gastrointestinal perforation

36
Peritonitis - Interdisciplinary Care
  • Pharmacology
  • broad-spectrum antibiotics until culture report
    obtained
  • narcotic analgesic, antipyretics
  • Surgery - laparotomy
  • peritoneal lavage
  • washing out cavity with copious amounts of
    isotonic soln
  • drains - JP or pen rose, may be left open

37
Nursing Care - Peritonitis
  • NGT
  • intestinal decompression
  • Pain - abd distention and inflammation
  • assess - location, severity and type - analgesics
  • fowlers - minimize stress on abd structures
  • alternative pain management - visualization,
    medication, relaxation

38
Nursing Care - Peritonitis
  • Fluid volume deficit
  • I O, vs, wt., assess for dehydration
  • Altered protection
  • monitor for sign of infection, handwashing,
    aseptic technique for drsg changes
  • Anxiety
  • potential threat to life

39
The Client with Viral or Bacterial Infection
  • Gastroenteritis
  • describes general GI inflammation
  • syndrome - diarrhea, vomiting, anorexia, nausea
    and pain
  • organisms - Staphlococcal, Salmonella,Shigella,
    Botulism - life threatening,
  • Cholera - third world countries
  • dx - stool culture, tx - antibiotics, rehydration

40
  • Ulcerative Colitis
  • chronic inflammatory bowel disorder of the mucosa
    and sub mucosa .
  • Affects young 15-40 yrs old
  • Cause
  • unknown, genetic component, autoimmune, dietary
    factors - fiber poor foods, smoking
  • Affects the large bowel

41
Ulcerative Colitis
  • Clinical Manifestations
  • insidious onset - attack last 1 to 3 months
  • diarrhea - 30 to 40 stools per day with blood and
    mucus
  • fatigue, anorexia, generalized weakness
  • toxic megacolon - transverse colon is paralyzed
    may rupture, massive hemorrhage - need colostomy

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44
Ulcerative Colitis
  • Interdisciplinary Care
  • supportive treatment
  • Dx - by sigmoidoscopy, edema, inflammation, mucus
    and pus
  • Pharmacology
  • Azulfidine - sulfonamide antibiotic, acts
    topically on colonic mucosa to inhibit
    inflammatory process
  • Dietary - npo with TPN, then low residue

45
Ulcerative Colitis
  • Surgery
  • not initial treatment
  • ileostomy
  • Nursing Care
  • relieving abd cramping
  • emotional support
  • teaching about illness and special needs
  • Nsg dx. - diarrhea and body image disturbance

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47
The Client with Crohns Disease
  • Slowly progressive, relapsing inflammatory
    disorder of GI tract
  • diarrhea less severe, no blood or mucus
  • RLQ pain, fever, malaise, fatigue
  • affect young people 10-30
  • can occur anywhere in the GI tract, patchy lesions

48
Crohns Disease
  • Interdisciplinary Care
  • therapy is directed toward managing the symptoms
    and controlling the disease process
  • Labs and Diagnostics
  • Stool specimen
  • X-ray - UGI with SBFT - shows ulcerations,
    strictures and fistulas
  • colonosocpy - bx

49
Crohns - Interdisciplinary Care
  • Pharmacology
  • same as ulcerative colitis - anti inflammatory
  • antidiarrheal - no risk of mega colon
  • Dietary
  • NPO - TPN, eliminate milk
  • Surgery
  • 2nd to complications, bowel obstruction - bowel
    resection

50
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52
Malabsorption Syndromes
  • A condition in which nutrients, carbohydrates,
    protein, fats, water, electrolytes, minerals, and
    vitamins are ineffectively absorbed by the
    intestional mucosa
  • mostly disease of small intestine
  • surgery of small intestine

53
Malabsorption Syndrome
  • Clinical manifestations
  • anorexia, abd bloating, diarrhea, weight loss,
    weakness, malaise, muscle cramps, anemia
  • signs of malnutrition
  • Celiac Disease
  • hypersensitivity to gluten, protein found in
    cereal
  • Tx - gluten free diet

54
Malabsorption Syndrome
  • Lactose Intolerance
  • deficiency of lactase the enzymes needed for
    digestion and absorbtion of lactose the primary
    carbohydrate in milk
  • affects 90 of Asians, 75 of African Americans,
    high incidence among Jewish and Hispanic
    populations
  • usually hereditary, symptoms occur in adolescence
    or early adulthood

55
Malabsorption Syndrome
  • Short Bowel Syndrome
  • from resection of significant portions of the
    small intestine
  • CA, mesenteric thrombosis with bowel infarction,
    Crohns disease or trauma
  • Treatment
  • frequent small, high caloric and high protein
    meals
  • multivitamin and mineral supplements

56
Neoplastic Disorders
  • Polyps
  • is a mass of tissue that arises from the bowel
    wall and protrudes into the lumen
  • occur most often in the sigmoid colon and rectum
  • 30 of people over age 50 have polyps
  • most are benign, some have potential to become
    malignant - are removed

57
Polyps
  • Interdisciplinary Care
  • Diagnosis made by barium enema and sigmoidoscopy
    or colonoscopy
  • Follow-up recommended because polyps tend to
    recur
  • Consider a silent disease - few or no symptoms
    with significant risk of CA

58
The Client with Colorectal Cancer
  • Malignant tumor arising from the epithelial
    tissues of the colon or rectum
  • 2nd leading cause of cancer death in Western
    countries
  • long term survival rate is only 35
  • occurs more in males than females
  • occurs after age 50

59
Colorectal Cancer
  • Risk Factors
  • over age 50
  • polyps in colon or rectum
  • cancer elsewhere in the body
  • family history
  • ulcerative colitis or crohns disease
  • radiation, immunodeficiency disease
  • dietary - high fat, high caloric, low Ca and
    fiber

60
Colorectal Cancer
  • Clinical Manifestations
  • no symptoms until it becomes advanced
  • slow growth pattern - 5-10yrs. for symptoms to
    develop
  • bleeding
  • change in bowel habit - diarrhea or constipation
  • pain, anorexia, weight loss - advance disease

61
Colon Cancer
62
Colorectal Cancer
  • Interdisciplinary Care
  • establish dx - colonoscopy
  • surgical intervention
  • adjuncts of chemotherapy and radiation

63
Colorectal Cancer
  • Surgical resection of tumor, adjacent colon and
    regional lymph nodes
  • Dukes Staging
  • Stage A - confined to bowel wall
  • Stage B - penetration of bowel wall
  • Stage C - lymph node involvement
  • Stage D - distant metastases

64
  • Permanent for tumors of rectum or sigmoid colon
  • Hartmann pouch temporary
  • the distal portion of the colon is left in place
    and sewn shut

Permanent f
65
Double Barrel colostomy
66
Nursing Care of the Client Having Bowel Surgery
  • Pre-operative
  • consent
  • assess level of understanding
  • bowel prep
  • oral and parental antibiotics
  • cathartics and enema to reduce risk of bowel
    contamination

67
Nursing Care of the Client Having Bowel Surgery
  • Post-operative Nursing Care
  • Routine post-op care
  • vital signs, turn, cough, deep breath q2hrs
  • I O - NGT drainage, surgical drains
  • assess for post-op hemorrhage
  • Assess for bowel sounds and distention
  • Provide pain relief
  • Assess resp. status - teach to splint

68
Nursing Care of the Client Having Bowel Surgery
  • Post-operative care
  • Assess position and patency of NGT
  • Assess stoma - color, size, check pallor
  • Assess stoma out-put - usually bright red
    initially then changing to clear greenish yellow
    by day 2-3
  • Encourage ambulation, this stimulates peristalsis
  • teach colostomy care

69
Nursing Care of Clients Having Bowel Surgery
  • Effects of ostomy on Body Image
  • adjust to loss of body organ and dx of cancer
  • show acceptance of client and ostomy
  • concerned over the affect of cancer
  • develop a trusting relationship
  • listen actively
  • ostomy, cancer support groups, social services

70
Colostomy Surgery
71
Case Study - Colorectal Cancer
  • W.C., 65yr old male, retired railroad employee,
    husband and father of 3 grown children. Has 3
    month history of small amount of blood and mucus
    in stool. Has a sensation of rectal pressure and
    has notice his stool has changed in diameter, now
    is pencil thin.

72
  • Physician palpates a tumor in the rectum.
  • Colonoscopy and bx confirm adenocarcinoma
  • W.C. is scheduled for a abdonminalperitoneal
    resection and sigmoid colostomy

73
  • His wife has many questions and asks, why does
    the colostomy have to be permanent?
  • Why does he need erythromycin and neomycin
    tablets?
  • She then asks, is he going to be ok?

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75
Physician Orders
  • Explain the rationale behind these orders
  • Insert NGT and connect to low intermintent
    suction
  • Insert foley catheter
  • Routine post-op v.s., OOB tonight
  • See PCA order sheet (M.S. 1mg q 10min, up to 10mg
    every 4 hours)
  • NPO

76
Nursing Interventions
  • Explain the rationale behind these interventions
  • establishing a therapeutic relationship
  • assessing patency and position of the NGT
  • assessing respiratory status
  • assessing b.s.
  • assess stoma and stoma output
  • teaching to splinting the incision

77
Structural and Obstructive Disorders
  • Hernia
  • protrusion of an organ or structure through a
    defect in the muscular wall
  • Inguinal hernias
  • 75 of all hernias
  • cause by improper closure of the tract that
    develops as the testes descend into the scrotum
    before birth
  • bulge at inguinal cannal
  • reducible - contents of the sac return to abd
    cavity
  • strangulated hernia - blood supply is compromised

78
Structural and Obstructive Disorders
  • Umbilical hernias
  • occur more frequently in women
  • obesity, mult. pregnancies, prolonged labor
  • tend to enlarge steadily
  • strangulation is common
  • Incisional or Ventral hernias
  • occur at previous surgical incision

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80
The Client with an Intestinal Obstruction
  • Occurs when intestinal contents fail to be
    propelled through the lumen of the bowel
  • Small intestine obstruction
  • ileum of small intestine most common site
  • Mechanical Obstruction
  • physical barrier, tumor or scar tissue
  • Functional Obstruction - paralytic ileus
  • peristalsis fails

81
Bowel Obstruction
82
The Client with an Intestinal Obstruction
  • Clinical Manifestations
  • cramping, colicky abdominal pain, can be
    intermittent or increase in intensity
  • vomiting
  • high-pitched tinkling bowel sounds - reflects the
    bowels attempt to propel contents past the
    obstruction
  • later stages - absent bowel sounds
  • electrolyte imbalance - hypovolemia - shock

83
The Client with an Intestinal Obstruction
  • Large Bowel Obstruction
  • usually occurs in sigmoid colon
  • cancer most common cause
  • Clinical Manifestations
  • abdominal pain and constipation
  • abdomen is distended and tender to palpation
  • Treatment for Bowel Obstructions
  • NGT - functional surgery - mechanical

84
Diverticulitis
85
The Client with Diverticular Disease
  • Diverticula
  • acquired saclike projections of mucosa through
    the muscular layer of the colon
  • 90-95 occur in the sigmoid colon
  • increased incidence in US, Australia, United
    Kingdom and France
  • related to cultural factors - diet high in
    refined foods and low in fiber

86
The Client with Diverticular Disease
  • Diverticulosis
  • the presence of diverticula
  • 80 are asymptomatic
  • Clinical Manifestations
  • left-sided abd pain, constipation and diarrhea
  • narrow stools, occult bleeding

87
The Client with Diverticular Disease
  • Diverticulitis
  • inflammation and microscopic perforation of
    diverticular mucosa
  • undigested food becomes trapped, blood flow is
    impaired - leads to abscess or peritonitis
  • Interdisciplinary Care
  • Chronic diverticular disease - dietary changes
  • Acute diverticulosis - bowel rest, antibiotics,
    eventually surgery

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89
Anorectal Disorders
  • The Client with Hemorrhoids
  • hemorrhoidial veins become weak, distended,
    develop varices - cause is straining, pregnancy
    also increases intra-abdominal pressure
  • internal or external
  • bleeding, bright red, unmixed with stool
  • pain associated with thrombosed or ulcerated

90
The Client with Hemorrhoids
  • Interdisciplinary Care
  • conservative therapy - diet, increase fiber,
    fluids, bulk forming laxative, Preparation H
  • surgery
  • sclerotherapy - inject chemical irritant to
    induce inflammation - fibrosis - scarring
  • rubber band ligation - rubber band placed snugly
    around - necrosis - slough
  • cryosurgery - necrosed by freezing with probe

91
The Client with Hemorrhoids
  • Nursing Care - post-op
  • inspect rectal dressing for bleeding
  • pain management - position of comfort - side
    lying
  • ice pack over rectal drsg
  • sitz bath tid and prn bowel movement
  • meds - analgesics, stool softeners

92
The Client with Anorectal Lesions
  • Anal Fissure
  • ulcers of the epithelium of the internal
    sphincter
  • Anorectal Abscess
  • bacteria invades pararectal space - I D
  • Anorectal Fistula
  • tunnel or tubelike tract - leaks stool
  • Pilonidal Disease - chronic draining sinus
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