Non-Inflammatory Bowel Disorders

Non-Inflammatory Bowel Disorders Hernia Colon Cancer Intestinal Obstruction Objectives Describe defining characteristics for the lower GI tract disorders discussed Develop intervention and teaching plans for the client with a lower GI tract disorder Appreciate the psychosocial impact of these disorders for the client and family Hernia Hernia—a protrusion of a portion of the bowel through an abnormal opening or weakness in the muscle wall. Common locations: inguinal (men) umbilical incisional femoral suprapubic Hernia Types of Herniation – Reducible – Irreducible – Strangulated: a surgical emergency Inspect for a bulge with client standing and supine, both while relaxed and while bearing down – Painless unless strangulation present – Nausea/vomiting, tachycardia when strangulated Hernia Herniorraphy: puts bowel back in place Hernioplasty: repairs muscle weakness Post op Care – – – – No coughing; deep breathe only No heavy lifting for 6-8 weeks Scrotal ice and support if inguinal hernia Monitor voiding pattern Colon Cancer Most prevalent in population >50 Risk factors include IBDs, polyps, constipation, high fat diet, & family hx Metastasis occurs through spread to organs adjacent to bowel or through circulatory & lymphatic systems; high incidence of liver metastasis Hallmark sx: rectal bleeding, anemia, and change in stool Colon Cancer S/S may vary with tumor location L sided tumor Constipation or pencil-thin stools Sensation of incomplete evacuation Cramping Blood streaked stool R sided tumor Fatigue Vague crampy/colicky type pain Occult blood in stool Anemia Colon Cancer Diagnostics Decreased H&H CEA elevated Stool for occult blood (+) Liver tests may be high Sigmoidoscopy or Colonoscopy for biopsy Barium Enema or CT Colon Cancer: Collaborative Care Treatment and prognosis depend on staging results. – Duke’s system most common • Graded 1-4 • A – no nodes, small lesion of mucosa only • B- distant metastasis Surgery: colon resection with or without colostomy; abdominal-perineal resection for rectal tumor – Pre-op bowel cleansing with neomycin, erythromycin, or Go-Lytely – Pre-op antibiotic – Referral to ET nurse Colon Cancer: Collaborative Care Ostomy monitoring includes – stoma character: pink & moist; may be edematous initially – stool characteristics and volume • Ileostomy stool is liquid • Ascending colostomy stool is semi-liquid • Descending colon stool is semi-formed – condition of surrounding skin: intact with a pouch that fits snugly Colon Cancer: Collaborative Care Client education includes dietary impact on ostomy: – – – – Odor producing foods e.g. eggs, broccoli Gas-forming foods e.g. soda, beer Stoma Obstructive: nuts, popcorn Diarrhea producing: fruit, coffee Psychosocial issues for the ostomy client: – Sexual function not disturbed, but altered body image may disrupt relationships – Refer to ostomy support group Colon Cancer; Collaborative Care Other post-op needs: For a-p resection: – Monitor rectal drainage – Sitz soaks – Check voiding Chemotherapy post-op, possibly pre-op Psychosocial support – Altered body image – Grieving – Ineffective coping Intestinal Obstruction Partial or complete obstruction that impedes flow of intestinal contents through GI tract Obstruction may result in – Fluid and electrolyte imbalance – Bowel ischemia Causes of Intestinal Obstruction Type Non-mechanical Mechanical (paralytic ileus) Decreased/absent Blockage inside the bowel (tumor,constipation) peristalsis d/t: *Surgery *Neuropathy *Intussusception (a proximal segment of bowel telescoped inside a distal segment) Blockage outside the bowel (adhesions, hernia) *Volvulus (a twisting of the intestine) Cause Signs/Symptoms of Obstruction Non-mechanical Mechanical Abdominal distention Abdominal distention Constant diffuse pain Intermittent colicky pain Vomiting, bile colored Vomiting, possibly fecal BS diminished or BS high pitched absent (borborygmi) then absent Constipated stool Diarrhea stool progressing to constipation (currant jelly stool if intussusception) Treatment of Obstruction Priority diagnoses: Fluid volume deficit Pain Non-Mechanical NPO Fluid & electrolyte replacement Pain management NG or NI tube to decompress abdomen Medications to increase gastric motility (Reglan) Mechanical NPO Fluid & electrolyte replacement Pain management Exploratory surgery *Intussusception: Barium Enema Inflammatory Bowel Syndromes Appendicitis Gastroenteritis Chronic: Ulcerative colitis Crohn’s disease Diverticular disease Acute: Appendicitis Inflammation of a blind pouch attached to the cecum Signs/Symptoms = PAINS Pain: periumbilical then localizes to RLQ Anorexia Increased temp & WBC (mild) Nausea/vomiting Signs: McBurney’s point rebound tenderness Appendicitis Diagnosis is by CT Sudden pain relief suggests perforation Treatment is immediate surgery – Post-op care is routine Gastroenteritis Acute illness of bacterial or viral origin manifesting as diarrhea or vomiting, which results in fluid & electrolyte imbalance – Clostridium difficile: a spore-forming bacillus that causes a range of illness from mild to death • Risk factors: exposure to antibiotics and HCPs • Control: Infection Control: dedicated equipment, cover gowns and gloves, and *******Wash hands with Soap & Water****** Gastroenteritis Nursing Assessment – – – – – Nausea/vomiting/diarrhea Generalized abdominal tenderness Hyperactive bowel sounds Signs of dehydration Stool spec may be sent for culture, WBC’s Gastroenteritis Nursing care is supportive – Fluid replacement po or IV – May need electrolyte replacement, esp. K – Diet: clear liquids for 24 hrs; increase as tolerated; bland foods; no caffeine – Drugs: antibiotics if bacterial cause suspected; avoid anti-motility agents • Rotovirus vaccine for chldren – Skin care – Infection Control!! Inflammatory Bowel Disease Inflammation of the bowel that leads to ulceration of the mucosa Client experiences periods of remission between exacerbations of disease Chronic disease is a risk factor for colon cancer Unknown cause: suspect auto-immune or genetic pre-disposition Primarily affects young females Inflammatory Bowel Disease Ulcerative Colitis Ulceration confined to mucosa of rectum & colon Bloody, mucousy diarrhea 10-20 stools/day Cramping & urgency (tenesmus), but pain less of an issue Crohn’s Disease Ulceration is transmural, non-continuous, anywhere along bowel Steatorrhea, 5-6 stools /day RLQ abdominal pain Inflammatory Bowel Disease Signs/symptoms common to both: weight loss fatigue perineal skin breakdown low grade fever psychosocial distress Inflammatory Bowel Disease: Complications Ulcerative Colitis Bowel obstruction Crohn’s Disease Bowel Obstruction Toxic Megacolon: bowel Fistula formation: obstruction d/t paralysis ulceration through all and dilatation of bowel layers of bowel into adjacent structure(s) Peri-rectal abscess: Severe malabsorption of infection in ulcerated area nutrients & electrolytes Inflammatory Bowel Disease Diagnostics – – – – H&H, Na, K, albumin may be low WBC and Sed rate may be high Fat in stool in Crohn’s disease Colonoscopy or BE; UGI in Crohn’s disease Treatment: Medications • Salicylates e.g. sulfasalazine, mesalamine, rowasa • Steroids used in exacerbations • Anti-diarrheal agents • Immunosuppressives e.g. cyclosporine in exacerbations to complement steroids • Monoclonal antibodies e.g.infliximab (Remicade) Inflammatory Bowel Disease: Collaborative Care Nutrition less than Body Requirements Diet: may be NPO and on TPN/PPN – TPN: high osmolarity calorie dense solution used when NPO >1 week; must run through central line – PPN: less calorically dense nutrition which may be run through a peripheral IV; used when nutrition support needed for <1 week Inflammatory Bowel Disease: Collaborative Care Important points of care for the client on TPN/PPN High risk for infection: run through filter; change bag and tubing every 24 hours; change lipids every 12 hours; dedicated IV line; aseptic IV site care High risk for fluid and electrolyte imbalance: monitor FBS; do not stop suddenly Inflammatory Bowel Disease: Collaborative Care Diet: when feeding resumes often needs high protein high calorie low fat diet with nutritional supplements Surgery: Colectomy with ileostomy or continent ostomy for Ulcerative Colitis • Ileostomy drains 2-3L/day of liquid stool initially NO SURGERY recommended for Crohn’s disease Inflammatory Bowel Disease: Collaborative Care Impaired skin integrity Potential for infection Activity intolerance d/t fatigue Ineffective coping d/t disease process Diverticular disease Diverticula: pouch-like herniation of the mucosal wall in the small bowel or colon d/t muscle wall weakness or intraluminal stress Diverticulitis: inflammation of diverticula Diverticular disease Nursing assessment LLQ abdominal pain tenderness to palpation nausea/vomiting fever and chills Diagnostics WBC high Stool for occult blood (+) CT in acute disease BE or UGI in non-acute disease Diverticular disease: Nursing care Infection – Antibiotics, anti-inflammatories – Rest; no straining or lifting Fluid & electrolyte imbalance – IV fluids to rehydrate Nutrition less than body requirements NPO or clear liquids initially; progress to high fiber diet when eating resumes; avoid foods with seeds Surgery: colon resection for rupture; possibly temporary colostomy