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Unit 10, Chapter 47: Management of Patients With Intestinal and Rectal Disorders�Part I�Constipation, Diarrhea, Irritable Bowel Syndrome, Inflammatory Bowel Disease

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Constipation

Is defined as fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass. (Abnormal in frequency or irregularity of defecation)>

Patient Learning Needs:

Normal variations of bowel patterns
Establishment of normal pattern
Dietary fiber and fluid intake
Responding to the urge to defecate
Exercise and activity
Laxative use

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Diarrhea

Increased frequency of bowel movements (more than three per day), and altered consistency (i.e., increased liquidity- looseness) of stool.
It can be associated with urgency, perianal discomfort, incontinence, nausea, or a combination of these factors
Patient Learning Needs:
Recognition of need for medical treatment
Rest
Diet and fluid intake
Avoid irritating foods, including caffeine, carbonated beverages, very hot and cold foods
Perianal skin care
Medications
May need to avoid milk, fat, whole grains, fresh fruit, and vegetables.

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Irritable Bowel Syndrome IBS

(IBS) is a chronic functional disorder characterized by recurrent abdominal pain associated with disordered bowel movements, which may include diarrhea (IBS-D), constipation (IBS-C), or both (IBS-M); OR classified as IBS-U for “unknown.”
Results from a functional disorder of the intestinal motility.
There is no evidence of inflammation or tissue changes (no anatomical changes) in the intestinal mucosa.
More common in Women than Men.
Factors of triggers include:
Heredity, Psychological Stress, Depression, Anxiety, High-fat diet, Irritating Foods, Alcohol & Smoking.

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Most common of clinical Manifestations

Alteration in bowel patterns
Abdominal Pain
Bloating: Uncomfortable feeling of fullness, tightness, or swelling in the abdomen.
Abdominal distention
Diagnostic Findings:
Stool Studies
Contrast Radiography Studies
Barium Enema
Colonoscopy

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Medical & Nursing Management

The goals of treatment are to relieve abdominal pain and control diarrhea or constipation. Lifestyle modification, including stress reduction, ensuring adequate sleep, and instituting an exercise regimen, can result in symptom improvement.
Medication management
Complimentary medicine: a wide variety of health care practices that may be used along with standard medical treatment.
Dietary changes & Food diary
Adequate fluid intake

Avoid Alcohol, Caffeine and Smoking

Relaxation techniques
A healthy, high-fiber diet if Constipated
Prevention of dehydration if there is Diarrhea

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Inflammatory Bowel Disease (IBD)

Includes Crohn’s Disease (regional enteritis) and Ulcerative Colitis.
IBD is mediated by both Genetic and Environmental factors (pesticides, food additives, tobacco, radiation)
Men are at a slightly higher risk for ulcerative colitis; whereas, women are at greater risk for Crohn’s disease
People between the ages of 20 and 29 are at greatest risk for Crohn’s disease; whereas, people between the ages of 15 and 30 are at greatest risk and those older than 60 years of age are at slightly greater risk for ulcerative colitis.
Current smokers are at risk for Crohn’s disease, but those who are ex-smokers or nonsmokers are at risk for ulcerative colitis.
Allergies and Immune disorders had also been suggested as causes.

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IBD

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Inflammatory Bowel Disease (IBD)

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is characterized by periods of remission and exacerbation. It is a subacute and chronic inflammation of the GI tract wall that extends through all layers
Is a chronic, recurrent inflammatory disease which involves any segment of the GI tract from mouth to anus but more common in the distal ileum and ascending colon.
Characterized by transmural inflammation (extends through all layers).
Frequently leads to intestinal obstruction, fistula, and

abscess formation.

As the disease progresses

the lumen narrows.

A. Crohn’s Disease (Regional Enteritis)

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Clinical Manifestations - Crohn’s Disease

Pain- right lower quadrant (RLQ)
Diarrhea
Scar tissue and formulation of granulomas
Abdominal tenderness and spasm
Weight loss, malnutrition, and secondary anemia
Abscess, fissures and fistula
Chronic Symptoms: Diarrhea, abdominal pain, steatorrhea, anorexia, weight loss, and nutritional deficiencies.
Joint pain, skin lesions, and oral ulcers

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Crohn’s Disease

Assessment and Diagnostic Findings:

Proctosigmoidoscopy
Stoll Examination: Occult blood and Steatorrhea
Barium Study & CT scan
Video Capsule Endoscopy
Endoscopy, Colonoscopy, and Intestinal biopsies
CBC
Complications:
Intestinal obstruction
Perianal disease
Fluid and electrolyte imbalance
Malnutrition from malabsorption

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B. Ulcerative Colitis

is a chronic ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum that is characterized by unpredictable periods of remission and exacerbation with bouts of abdominal cramps and bloody or purulent diarrhea.

A nonspecific inflammatory condition of the colon (unknown cause) and rectum.
Superficial ulcers seen in mucosa

Bleed
Become edematous
Become abscessed causing reduced absorptive surface of the bowel

May be seen more with

structured persons who tend

to be perfectionistic.

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Ulcerative Colitis- Manifestations

Physical

Frequent diarrhea
Stool with mucus, blood, pus
Colicky abdominal cramps, distention
Low grade fever
Fluid and electrolyte imbalance
Weight loss, anorexia
Weakness and cachexia

Psychosocial/Cultural

Occurs most often in

Adolescents
Young adults

Causes depression, anger, frustration
Stress may cause exacerbation

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Ulcerative Colitis

Assessment and Diagnosis

Assess for tachycardia, hyoptension, tachypnea, fever, and pallor.
Assess hydration and nutritional status
Physical examination of abdomen
Assess stool for blood (+ve) & CBC
Abdominal X-ray, CT scan, MRI, or Ultrasound
Sigmoidoscopy, Colonoscopy, or Barium enema
Complications: Toxic mega-colon, perforation, and bleeding as a result of ulceration, vascular engorgement, and highly vascular granulation tissue.

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Management of Patients with IBD

Nutritional Therapy: Oral fluid, low-residue, high protein, high calorie diet, supplemental vitamin & iron replacement.
Avoid food that exacerbate diarrhea; milk, cold foods
Pharmacologic Therapy: Sedatives, Antidiarrheal, & Antiperistaltic medications to rest inflamed bowel
Aminosalicylates (Sulfasalazine), Antibiotics (Metronidazole), Corticosteroids (Prednisone)
Surgical: Strictureplasty, and intestinal transplant (newly developed), total colectomy with ileostomy.

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Nursing Process: Inflammatory Bowel Disease—Assessment

Health history to identify onset, duration and characteristics of pain, diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history.
Discuss dietary patterns, Alcohol, caffeine, and nicotine use
Assess bowel elimination patterns and stool
Abdominal Assessment

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Nursing Process: IBD— Diagnoses

Diarrhea
Acute Pain
Deficient Fluid & Imbalanced Nutrition
Activity Intolerance
Anxiety & Ineffective Coping
Risk for Impaired Skin Integrity
Risk for ineffective therapeutic regimen management
Complications:
Electrolyte Imbalance
Cardiac Dysrhythmias
GI bleeding with fluid loss
Perforation of the bowel

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Nursing Process: IBD— Planning

Major goals may include:
Attainment of normal bowel elimination patterns
Relief of abdominal pain and cramping
Prevention of fluid deficit
Maintenance of optimal nutrition and weight
Avoidance of fatigue
Reduction of Anxiety
Promotion of effective coping
Absence of skin breakdown
Increased knowledge of disease process and therapeutic regimen
Avoidance of complications

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Maintaining Normal Elimination Pattern

Identify relationship between diarrhea and food, activities, or emotional stressors.
Provide ready access to bathroom
Encourage bed rest to reduce peristalsis
Administer medications as prescribed
Record frequency, consistency, character, and amounts of stools.

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Other Interventions

Assessment and treatment of pain or discomfort, Anticholinergic medications before meals, analgesics, positioning, diversional activities, and prevention of fatigue.
Fluid Deficit, I&O, daily weight, assessment of symptoms of dehydration or fluid loss, encourage oral intake, measures to decrease diarrhea.
Optimal Nutrition; elemental feedings that are high in protein and low residue or PN may be needed
Reduce Anxiety, use a calm manner, allow patient to express feelings, listening, patient education

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Patient Education

Understanding of disease process
Nutrition and diet
Medications
Information sources: National Foundation for Ileitis and Colitis
Ileostomy care if applicable

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Acute Inflammatory Intestinal Disorders

A. Appendicitis
The appendix becomes

Inflamed, swollen, and gangrenous
It eventually perforates if not treated.

Appendicitis is related to intraluminal obstruction with

A fecalith (i.e., hard piece of stool)
Gallstones
Tumors
Parasites
Lymphatic tissue

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Appendicitis

Clinical Manifestations: Vague epigastric or periumbilical pain progress to RLQ, low grade fever, loss of appetite, nausea & some time vomiting.
Assessment and Diagnosis:

History and physical examination (Rebound tenderness, Iliopsoas & Obturator test)
Laboratory tests (e.g., CBC)
Imaging studies (abdomen x-ray, Utrasound, or CT)

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Appendicitis

Complication:

- Perforation

- Peritonitis

- Abscess

Medical Management:

- Appendectomy

- Analgesigc

- Antibiotics

- I.V fluid & electrolytes replacement