Lesson 3

Nursing Management: Patients with Gastric and Duodenal

Disorders
Pellico Chapter 23
ATI Med Surg Chapters 47, 49 & 50
ATI Nutrition Chapter 13
ATI Pharm Chapter 28
Karch Chapter 59

Shauna Winchester, MSN, RN

Objectives
Compare the etiology, clinical manifestations,
and management of acute gastritis, chronic
gastritis, and peptic ulcer.
Describe the management of the patient with
gastritis.
Describe the dietary, pharmacologic, and
surgical treatment of peptic ulcer.
Describe the nursing management of patients
who undergo surgical procedures to treat
obesity.
Use the nursing process as a framework for care
of patients undergoing gastric surgery.
Educate patient regarding an acute or chronic
gastric or duodenal condition.

Objectives

Describe the therapeutic actions, indications,

pharmacokinetics contraindications, most common
adverse reactions, and important drug- drug interactions
associated with the following types of gastrointestinal
medications:
Drugs that affect GI secretions
Compare and contrast the prototype drugs with the other
drugs in that class for the following types of
gastrointestinal medications:
Drugs that affect GI secretions
Outline the nursing considerations and teaching needs
for patients receiving the following:
Drugs that affect GI secretions

Gastritis
Inflammation of gastric mucosa
Irritants
Aspirin, NSAIDS, Excessive alcohol use, caffeine

Result of break in protective barrier

Types:
Acute Gastritis
Chronic Gastritis

Manifestations of Gastritis
Acute: abdominal discomfort, headache, lassitude, nausea,
vomiting, hiccuping.
Chronic: epigastric discomfort, anorexia, heartburn after
eating, belching, sour taste in the mouth, nausea and
vomiting, intolerance of some foods. May have vitamin
deficiency due to malabsorption of B12.
May be associated with achlorhydria, hypochlorhydria, or
hyperchloryhydria.
Diagnosis is usually by UGI X-ray or endoscopy and
biopsy.

Medical Management of Gastritis

If acute
Education

Instruct patient to refrain from alcohol and food

until symptoms subside then nonirritating diet. If
symptoms remain IV fluids.

Treatment
If r/t ingestion of strong acids or alkalis
Neutralize

Supportive therapy
Fiberoptic Endoscopy
Gastrojejunostomy
NG, analgesics, sedatives, antacids, IV fluids

Medical Management of Gastritis

If chronic- may require vitamin B12 for prevention or
treatment of pernicious anemia.
Education
Diet- non irritating, rest, reduce stress, avoid alcohol
and smoking, and NSAIDS

Drug therapy
Pharmacologic therapy (See Table 23-1)
H2 Receptor Antagonists
PPIs
Antacids
Mucosal protectant

We discussed
these in Part 1.

GI Protectant
Sucralfate (Carafate)
Coats injured area in the stomach to prevent
further injury from acid
PO
Tx of duodenal ulcers, maintenance of duodenal
ulcers after healing, tx of oral and esophageal
ulcers due other factors such as chemo, under
investigation for tx of gastric ulcers and gastric
damage r/t NSAIDS, and stress ulcers in acutely ill

GI Protectant

Prostaglandin
Misoprostol (Cytotec)
Inhibits gastric acid secretion and increases
bicarb and mucous production in the stomach
PO
Prevention of NSAID induced ulcers in adults at
high risk for developing gastric ulcers, under
investigation for tx of duodenal ulcers in pts who
are not responsive to other treatment

Prostaglandins

Question
The nurse is teaching a patient about health
promotion and maintenance to prevent chronic
gastritis. Which information should the nurse
include? (Select all that apply)
A. A balanced diet can help prevent gastritis.
B. To prevent gastritis, you should limit you calcium
intake.
C. If you stop smoking, there is less of a chance you will
develop gastritis.
D. Yoga has been found to be effective.
E. Drink alcohol only 5 days a week.

Peptic Ulcer
Erosion of a mucous membrane forms an excavation in
the stomach, pylorus, duodenum, or esophagus
Associated with infection of H. pylori
Manifestations include a dull gnawing pain or burning in
the mid-epigastrium; heartburn and vomiting may occur
Comparison of duodenal and gastric ulcer (Table 23-2 p 636)

Mucosal lesion of the stomach or duodenum

Types
Gastric ulcers
Duodenal ulcers
ZES
Stress-related mucosal disease (SRMD)

Risk Factors

Occurs in those 40-60 years of age

Uncommon in women of childbearing age
Has been observed in children and infants
After menopause women and men=
H-pylori
Excessive secretion of HCL
Familial tendency
Blood type O more susceptible
Associated with chronic renal or pulmonary disease
Other factors
Chronic use of NSAIDs, alcohol ingestion, and excessive smoking

Clinical Manifestations
May have no symptoms or may last days, weeks,
months and then disappear and reappear
Complains of dull, gnawing pain or burning
sensation in the midepigastrium or in the back
Other symptoms
Pyrosis, vomiting, constipation, or diarrhea, and
bleeding

Ulcer Comparison
Duodenal Ulcer

Most common
Hypersecretion of stomach
acid
May have wt gain
Pain 2-3 hours after a meal
Often pain will awaken 1-2am

Ingestion of food relieves pain

Vomiting uncommon
Hemorrhage less likely
Melena more common than
hematemesis

Gastric Ulcer

Less common
Normal to hyposecretion of
stomach acid
Weight loss may occur
Pain -1hr after a meal
Pain rare at night
Pain may be relieved by
vomiting
Ingestion of food does not help
sometimes increases pain
Vomiting common
Hemorrhage more common
Hematemesis more common
than melena

Question
Which assessment data supports to the nurse the clients
diagnosis of gastric ulcer.
A. Presence of blood in the clients stool for the past
month.
B. Reports of a burning sensation moving like a wave.
C. Sharp pain in the upper abdomen after eating a heavy
meal.
D. Complaints of epigastic pain 30-60 minutes after
ingesting food..

Diagnostics
Barium study of upper GI
Endoscopy preferred
Biopsy

Gastric secretory studies

H pylori
Serologic testing for antibodies
Stool antigen test
Urea breath test

Nursing Management
Treatment of peptic ulcers with antibiotics to
eradicate H. pylori
Lower reoccurrence rate

Treatment includes
Lifestyle changes
Medications (See Table 23-3)
Ulcer healing- H2 receptor antagonists (dine) and
PPIs along with bismuth salts to suppress or
eradicate H pylori
Prophylactic therapy for NSAID ulcers PPIs and
Prostaglandin analog misoprostol
H-pylori tx

Occasionally surgery (See Table 23-4)

Gastric Surgery
Gastrectomy- removal of all or part of stomach
Antrectomy- removal of antrum portion of
stomach
Vagotomy- severe branches of the vagus nerve
Pyloroplasty- enlargement of the opening
between the stomach and small intestine

Surgical Procedures for Peptic Ulcers

Complications
Hemorrhage (Most common)[GI bleed]
Hematemesis
Melena

Management of hemorrhage

Assess for evidence of bleeding, hematemesis or melena, and

symptoms of shock/impending shock and anemia.
Treatment includes IV fluids, NG, and saline or water lavage;
oxygen, treatment of potential shock including monitoring of
VS and UO; may require endoscopic coagulation or surgical
intervention.

Complications
Management of perforation

Signs include severe upper abdominal pain that may be referred

to the shoulder, vomiting and collapse, tender board-like
abdomen, and symptoms of shock/impending shock.
Patient requires immediate surgery.

Management of penetration
Back and epigastic pain not relieved by meds that were effective
before
Patient requires immediate surgery.

Pyloric obstruction

Symptoms include nausea and vomiting, constipation,

epigastric fullness, anorexia, and (later) weight loss.
Insert NG tube to decompress the stomach, provide IV fluids
and electrolytes. Balloon dilation or surgery may be required.

Question
You are providing discharge teaching to you client
regarding taking a proton pump inhibitors.
Which information would you want to stress to
the client?
a. Before meals
b. With a meal
c. Immediately after the meal
d. One to three hours after the meal

Morbid Obesity
People who are > 2x their ideal body weight
(IBW)
More than 100 pounds greater than IBW
Body mass index (BMI) exceeds 30
Risk factors

Diabetes
Cardiovascular disease
Cancer
Osteoarthritis
Asthma
Sleep apnea
Depression

Medical Management

Weight loss regimen

Behavioral modification
Exercise program
Antidepressants
Appetite Suppressants
May have a 10% in wt reduction
Sibutramine HCL (Meridia)- inhibits reuptake of serotonin and
norepineprhine and appetite. Recently pulled from the
market linked to heart attack and stroke
Orilast (Xenical) - prevents digestion of fats by binding to
gastric and panreatic lipase (alli over the counter)
Rimonabant(Acomplia)- newest blocks the cannabinoid-1
receptor that is thought to play an important role in
metabolism

Bariatric Surgery
Average wt loss after sx is 61%
Improvement seen in comorbid conditions
6-12 months of counseling and education prior to sx
After sx will require lifelong monitoring of wt loss
Risk of malnutrition and wt gain
Surgery is preformed only after nonsurgical methods
have failed.
Selection factors include body weight, patient history,
and failure to lose weight using other means, absence of
endocrine disorders, and psychological stability
Table 23-5 Selection criteria

Procedures
Figure 23-3 pg 644
Combined restrictive and malabsorptive procedure
Roux-en-Y gastric bypass

Restrictive procedures
Gastric banding
Vertical banded gastroplasty

Gastric restriction with intestinal malabsorption

Biliopancreatic diversion with duodenal switch

May be performed
Laparoscopy
Open surgical technique

Surgical intervention after wt loss:

Panniculectomy
Lipoplasty

Complications
Most common
Bleeding, blood clots, bowel obstruction,
incisional or ventral hernias, and infection.

Other symptoms

Nausea
Dumping syndrome
Diarrhea
Constipation
Nutritional deficiencies
Table 23-6

Nursing Mgmt: post op

Monitor complications
6 small feedings consisting of a total of 600-800
calories after bowel sounds have returned and
oral intake is resumed
Monitor fluid intake to help prevent dehydration
Usually discharged 23-72 hrs after laparoscopic
procedure

Patient Education after Bariatric Surgery

Pt education: See chart 23-2
Eating fast or too much can cause esophageal distention and
vomiting
Dont drink fluids with meals
Drink plenty of water
90 min after each meal
15 min before the next meal
Eat three meals per day containing protein and fiber
Eat only foods packed with nutrients
Avoid liquid calories such as alcohol, fruit drinks, regular sodas
Include two protein snacks per day
Total meal size less than 1 cup
Eat slowly
Chew thoroughly
Walk for at least 30 min per day

Gastric Cancer

More common in people over age 40

Incidence has decreased in US
Increased risk in men
Increased incidence in Japanese
Native Americans, African Americans, Hispanic
population at greater risk for gastric ca than Caucasians
Poor prognosis
Risk factors

Diet
Chronic inflammation of stomach
Pernicious anemia
Achlorhydria
Gastric ulcers
H. pylori infection
Hx of subtotal gastrectomy

Gastric Cancer
Patho

Most are Adenocarcinomas

May occur in any portion of the stomach but most occur in
the lesser curvature of the stomach
Metastases often present at time of diagnoses
Most common sites of mets are pancreas, liver, esophagus,
and duodenum

Clinical Manifestations

May be asymptomatic in early stages

Dyspepsia
Early satiety
Wt loss
Abdominal pain above umbilicus
appetite
Bloating after meals, N, V

Assessment
EGD test of choice
Barium x-ray of upper GI tract
CT to detect mets
Ascites and hepatomegaly may be present if liver
involvement
May be able to palpate nodules around the
umbilicus (Sister Mary Josephs nodules)

Surgical management

Diagnostic laparoscopy to evaluate disease

May be curative if tumor localized to stomach
May be palliative if distant mets
Total gastrectomy removal of stomach,
duodenum, esophagus attached to the stomach,
supporting mesentery and lymph nodes
Subtotal gastrectomy- Billroth I or Billroth II

Treatment
radiation therapy- palliative
Chemotherapy- 5FU, cisplatin, doxorubicin,
etoposide, and mitomycin-C
Improved response
Combination therapy 5FU and other agents

Tumor marker assessment to monitor

effectiveness of treatment:
CA 19-9
CA 50
CEA

Patient Undergoing Gastric Surgery

Assessment
Pt and family knowledge pre and post op
Assess nutritional status

Lost weight? If so obtain more info

Nausea/vomiting
Hematemesis
Abdominal assessment
Bowel sounds and palpates abdomen

After surgery
Hemorrhage, infection, abdominal distention,
atelectasis or impaired nutritional status

Planning
Major goals include reduced anxiety, increased
knowledge, optimal nutrition, management of
complications that can interfere with nutrition,
relief of pain, avoidance of hemorrhage and
steatorrhea, and enhanced self-care skills at
home.

Interventions
Reduce anxiety

Provide a relaxed, nonthreatening atmosphere.

Allow patient to express fears and concerns.
Provide support and encourage family support.
Promote positive coping measures.
Explain treatments and procedures.

Pain

Administer analgesic as prescribed

Monitor effectiveness

Nonpharmacologic pain relief measures

Position

Maintain NG tube

Prevent distention

Teaching

Explain pre and post op procedures

Interventions
Resuming enteral intake
May already be malnourished
Enteral/Parenteral
After return of bowel sounds and NG
removal
May give fluids and small amount of food
Foods gradually added until pt can
tolerate six small meals a day and drink
120mL between meals

Interventions
Recognizing obstacles to adequate nutrition
Dysphagia
Gastric retention-nausea, vomiting, abdominal distention
May require reinstatement of NPO and Ng suction. Use lowpressure suction

Bile reflux
May occur with removal of pylorus
Burning epigastric pain and vomiting
TX with cholestyramine (Questran), antacid, metoclopramide
hydrochloride (Reglan)

Dumping Syndrome

Due to rapid passage of food into the jejunum and drawing of fluid
into the jejunum due to hypertonic intestinal contents.
Causes vasomotor and GI symptoms with reactive hypoglycemia
Avoid fluid with meals
Avoid high carbohydrate/sugar intake

Dietary Self-Management After Gastric Surgery

To delay stomach emptying and dumping syndrome assume
low Fowlers position after meals; lie down for 20-30
minutes.
Take antispasmodics as prescribed.
Avoid fluid with meals.
Meals should contain more dry items than liquid items.
Eat fat as tolerated, but keep carbohydrate intake low, and
avoid concentrated carbohydrates.
Eat small, frequent meals.
Take dietary supplements as prescribed; vitamins, mediumchain triglycerides, and B12 injections.

Question
Which statement about general principles of diet therapy
for patients with dumping syndrome is true?
A. Patients with dumping syndrome should have liquids
between meals only.
B. Patients with dumping syndrome should be
encouraged to eat a diet high in roughage.
C. Patients with dumping syndrome should eat a high
carbohydrate diet.
D. The diet for a patient with dumping syndrome must
be low in fat and protein.

Interventions
Obstacles to adequate nutrition

Steatorrhea
Reduce fat intake and administer loperamide
Malabsorption of vitamins and minerals
Supplementation of iron and other nutrients
Parenteral administration of vitamin B12 due to lack
of intrinsic factor
May require Fe and Vitamin B12 supplements
IM B12 1xmo in pts with total gastrectomy

Interventions
Monitoring for s/sx of potential complications
Hemorrhage
Monitor for s/s of shock
Monitor NGT output and abd drsg

Duodenal Tumors
Usually benign
Uncommon
Asymptomatic most of the time
If symptomatic
Intermittent pain or occult blood
May place at higher risk for malignancy

Malignant
Cause signs and symptoms
Many times not discovered until metastasized to distant sites
Clinical manifestations
Weight loss
Malnutrition
Bleeding
Pain

Duodenal Tumors
Diagnosis
Upper GI
Entercolysis
Abdominal CT

Nursing management
Benign tumors
If symptomatic
Excision/resection or electrocautery

Duodenal tumors
Malignant tumor
Most common-adenocarcinoma
Second and third portion of the duodenum involved
Symptoms
Bleeding or duodenal obstruction

If located in Ampulla of Vater-Jaundice

Treatment
Surgery
Chemo and radiation

Nursing care

Lesson 4: Nursing Management: Patients with Intestinal and

Rectal Disorders
Pellico Chapter 24
ATI Chapter Med Surg 51 and 52
ATI Nutrition Chapter 13
ATI Pharm Chapter 29

Shauna Winchester, MSN, RN

Objectives
Describe the health care needs of patients with
constipation, diarrhea, or fecal incontinence.
Compare the conditions of malabsorption with regard to
their pathophysiology, clinical manifestations, and
management.
Describe diverticular disease and the care of patients
with diverticulitis.
Compare and contrast regional enteritis and ulcerative
colitis regarding their pathophysiology, and medical,
surgical, and nursing management.
Identify the care needs of the patient with inflammatory
bowel disease.

Objectives
Describe the responsibilities of the nurse in meeting the
needs of the patient with an ileostomy.
Describe the various types of intestinal obstructions, as
well as their medical and nursing management.
Describe the pathophysiology, assessment, and
management in regards to cancer of the colon or rectum.
Describe anorectal conditions including fissures, fistulas,
hemorrhoids, and sexually transmitted anorectal
diseases.
Identify the complications of gastric surgery and their
prevention and management.
Educate patient regarding an acute or chronic intestinal
or rectal condition.

Objectives
Describe the therapeutic actions, indications, pharmacokinetics
contraindications, most common adverse reactions, and important
drug- drug interactions associated with the following types of
gastrointestinal medications:
Laxatives and antidiarrheals
Antiemetic agents.

Compare and contrast the prototype drugs with the other drugs in that
class for the following types of gastrointestinal medications:
Laxatives and antidiarrheals
Antiemetic agents.

Outline the nursing considerations and teaching needs for patients

receiving the following:
Laxatives and antidiarrheals
Antiemetic agents.

Irritable Bowel Syndrome

Functional disorder of intestinal motility.
Risk factors

Heredity
High fat diet or stimulating or irritating foods
Alcohol
Smoking
Stress
Depression
Anxiety

Symptoms range: constipation, diarrhea or a combination of both.

Pain, bloating, abdominal distention, abdominal pain often caused
by eating and is relieved by defecation.
Assessment and diagnostic findings

Irritable Bowel Syndrome

Medical management: relieve abdominal pain,
control diarrhea or constipation, reduce stress,
good dietary habits, keep symptom and food
diary, fluids not taken at meals and medications.

Bulk forming laxative (Metamucil)

Antidiarrheal agents loperamide (Imodium)
Anticholinergics
Antidepressants
tegaserod (Zelnorm) withdrawn from market
alosetron (Lotronex) ATI pg 571 Karch pg 990
lubiprostone (Amitiza) ATI pg 572 Karch pg 990

 Antidepressants

Tegaserod (Zelnorm)
Removed from market

Question
The nurse is teaching a patient with IBS about
ways to help manage the IBS. Which patient
statements indicate that teaching has been
effective?
A. I should eat a low-fiber diet.
B. Fish oil can be used to ease constipation.
C. I should exercise regularly to help manage
the disease.
D. I should drink with my meals.

Malabsorption
Inability to absorb one or more of the major
vitamins, minerals, and nutrients.
Patho
Risk factors
Abdominal diseases or deformities, surgery,
radiation, and certain meds that inhibit bacterial
growth such as antibiotics. Use of mineral oil or
laxatives increase peristalsis.

Malabsorption
Clinical manifestations (Table 24-2)
Diarrhea, or frequent, loose, bulky, foul-smelling, stools
increased fat and gray in color. Abdominal distention, pain,
increased flatus, weakness, weight loss, decreased sense of
well-being. Malnutrition and weight loss.

Diagnostic test
Endoscopy with biopsy of the mucosa

Medical and nursing management

Avoiding dietary substances that aggravate and using
supplements. Managing primary diseases. Antibiotics,
antidiarrheal agents and parenteral fluids.
Education and ongoing assessment

Malabsorption
Complications
Using corticosteroids

Hypertension
Hypokalemia
insomnia
Euphoria

Using antibiotics
Reduce vit K producing intestinal flora
Prolonged PT and INR with pts taking Warfarin

Using anticholinergics
Urinary retention
Altered mental status
Glaucoma

Appendicitis
Acute inflammation of the vermiform appendix
the blind pouch attached to the cecum of the colon
S/S: vague, dull or poorly localized epigastric or
periumbilical pain progresses to RLQ pain that is
sharp, well localized, loss of appetite, local
tenderness at McBurneys point, poss rebound
tenderness, Rovsings sign, fever of 100F or greater,
nausea
If appendix has ruptured, the pain becomes more
diffuse, abdominal distention, pt condition worsens.

Appendicitis
Constipation- Do not administer laxatives or
cathartics to a pt who has fever, nausea and
abdominal pain.
Cause perforation

Diagnostic testing
Physical exam and imaging studies, CBC (elevated WBC with
elevated neutrophils), abdominal x-ray, ultrasound, CT, or
laparoscopy

Acute appendicitis is uncommon in elderly

Perforation is higher because vague symptoms and
not seeking healthcare.

Appendicitis
Nursing management

Fluids antibiotic therapy are administered until surgery.

Immediate surgery if appendicitis is diagnosed
Avoid enemas can cause perforation
Post-op

High Fowlers-reduce tension on incision

Pain relief-Opioid
Oral fluids when tolerated
IV fluids for the pt that was dehydrated
Once normal bowel sounds-food as tol
Discharge teaching-follow up 5-7 days suture removal, care
for incision, may resume normal activity 2-4 weeks.

Appendicitis
Complications (Table 24-3 p 663)

Peritonitis
Pelvic abscess
Subphrenic abscess
Illeus

Diverticular disease
Patho
Diverticula, Diverticulitis, Diverticulosis

Risk factors
Hx of diverticulitis
Congenital predisposition in those under 40

Clinical Manifestations of diverticulosis

May have no symptoms
Mild symptoms
Bowel irregularities, with diarrhea, nausea, anorexia and abdominal
distention.

Repeated inflammation
Large bowel can narrow-cramps, narrow stools, and increased
constipation or obstruction.
Weakness, anorexia, and fatigue

Clinical manifestations of diverticulitis

Acute onset of mild to severe pain in LLQ, nausea, vomiting, fever,
chills, and leukocytosis

Diverticular disease
Diagnostic

Colonoscopy- view and biopsy to rule out other diseases

Barium enema-avoided if there are symptoms of peritoneal
irritation- lead to perforation.
CT scan test of choice if diverticulitis is suspected
Abdominal X-rays
CBC
Elevated WBC and ESR

Gerontologic considerations

Increased incidence with aging

Symptoms less pronounced
Delay reporting symptoms
Blood in stool is often overlooked

Diverticular disease
Nursing management
Diverticulitis
Diet
Medication

Acute diverticulitis

Hospitalization
Rest bowel
Broad spectrum antibiotics 7-10 days
Opoid
Avoid NSAIDS-increased risk of perforation
Antispasmodics
Supplement dietary fiber for normal stools
Metamucil
Stool softeners
Warm oil in rectum
Suppository

Diverticular disease
If medical management does not work
Surgery for complications
CT guided percutaneous abscess drainage and
antibiotics if no complications
Types of surgery
One staged resection
Multiple stage (Figure 24-3p 664)

Complications
Peritonitis
Abscess formation
Bleeding

Question
The nurse is working in an outpatient clinic.
Which client is most likely to have a diagnosis of
diverticulosis?
A. A 60 year old male with a sedentary lifestyle.
B. A 72 year old female with multiple
childbirths.
C. A 63 year old female with hemorrhoids.
D. A 40 year old male with a family history of
diverticulosis.

Peritonitis
Inflammation of the peritoneum, the serous membrane
lining the abdominal cavity and covering the viscera.
Life threatening

Caused by a leakage of contents from abdominal organs

into the abdominal cavity, usually result of:
Inflammation, infection, ischemia, trauma, or tumor
perforation.

Peritonitis
Life-threatening
Primary or secondary
Diffuse abdominal pain
Constant localized and more intense

Rigid, boardlike abdomen

Distended abdomen
Temperature (100-101)
Usually N&V
Tachycardia
Nausea and vomiting

Peritonitis
Diminished perception of pain
Taking corticosteroids, analgesics, diabetics with
neuropathy, and pts with cirrhosis who have ascites

Assessment and Diagnostic Findings

WBC, hgb, hct, electrolytes, abdominal X-ray, ultrasound,
and CT

Peritonitis
Nursing management

Fluid, colloid, and electrolyte replacement

Isotonic solution is emergent due to hypovelemia
Anaglesics
Antiemetics-N & V
NG with suction-relieve distention
O2/intubation
Large doses of broad spectrum antibiotics
Antifungicide
Surgical tx: removed infected material
Complications
Perforation
Abscess

Peritonitis
Monitor BP via arterial line if shock
I & O, CVP, PAP, monitor IV response
Ongoing assessment
Pain, GI function, fluid and lytes balance, and position
Watch for signs subsiding
Observe drainage
Drains from being dislodged
Incision care
Discharge teaching
Home care
Complications
Sepsis
Shock
Pulmonary emboli

es

Question
The client diagnosed with diverticulitis is
complainant of severe pain in the left lower
quadrant and has an oral temp of 100.6 F.
Which intervention should the nurse implement
first?
A. Notify the health care provider
B. Document the finding in the chart
C. Administer an oral antipyretic
D. Assess the clients abdomen

Inflammatory bowel disease (IBD)

Regional enteritis (Chrohns disease) and
ulcerative colitis
Incidence has increased in US
Presents during childhood or later in life and is
associated with a high morbidity and decreased quality
of life
Family history predisposes
Smokers Chrohns disease
Non-smokers ulcerative colitis
Cause unknown
Triggered by
Radiation, tobacco, food additives, and pesticides

Regional enteritis (Chrohns disease)

Usually first diagnosed in adolescents or young adults,
but can appear at any age.
Inflammation and ulceration of the GI tract
Can occur anywhere in the GI tract
Can involve the entire GI tract from the mouth to anus
Often at the distal ileum (most common)
Can appear in the ascending colon

Cobblestone not continuous separated by normal tissue

Fistulas, fissures, and abscesses form

Inflammation extend into the peritoneum
Granulomas occur in 50%
Bowel wall thickens and intestinal lumen narrows

Regional enteritis (Chrohns disease)

Clinical manifestations

Usually characterized by periods of remission and

exacerbation
RLQ abd pain unrelieved by defecation and diarrhea
Cramping pain
Abdominal distention, tenderness and/or firmness
upon palpation
Fever
Anorexia
Weight loss
Malnutrition
Anemia

Disrupted absorption causes chronic diarrhea and

nutritional deficits
Diarrhea in about 20%
5 loose stools per day with mucus or pus

Regional enteritis (Chrohns disease)

Inflamed intestine may perforate intra-abdominal and anal
abscesses, fever, and leukocytosis
Chronic symptoms steatorrhea
S/sx extend beyond GI tract and affect other organs and areas of
body.
Arthritis, skin lesions, conjunctivitis, oral ulcers

Diagnosis

Proctosigmoidoscopy, endoscopy, colonoscopy

Stool sample steatorrhea or occult blood
Barium study of upper GI most conclusive
Shown constriction of the ileum

Barium enema-cobblestone
CT scan bowel wall thickening and fistula formation
CBC decreased hgb and hct, elevated WBC, ESR elevated, albumin and
protein decreased

Regional enteritis (Chrohns disease)

Complications
Intestinal obstruction or stricture, perianal
disease, fluid electrolyte imbalances, malnutrition,
fistula and abscess formation
Most common fistula
Enterocutaneous fistula

Increased risk of colon cancer

Ulcerative colitis
Ulcerative colitis-recurrent ulcerative and inflammatory
disease of the mucosal and submucosal layers of the colon
and rectum.
Affects the superficial mucosa of the colon
Characterized by multiple ulcerations, diffuse
inflammations, and desquamation or shedding of the colonic
epithelium
Bleeding
Mucosa edematous and inflamed
Lesions one after another touching
Abscesses
Begins in the rectum spreads to the entire colon
Bowel narrows, shortens, thickens

Ulcerative colitis
Abdominal pain LLQ
Cramping
Usually characterized by diarrhea
Up to 15-20 stools per day

Passage of mucus blood or pus can be present

Rectal bleeding which can be mild to severe

Pallor, anemia, and fatigue result

Rebound tenderness in RLQ may occur

Usually presents with intermittent exacerbations and remissions.
Classified
Mild
Severe
Fulminant
May affect other organs or areas of body.
Arthritis, skin lesions, eye lesions, liver disease

Ulcerative colitis
Assessment
Diagnostics

Stool - positive for blood or parasites

Labs
Abdominal X-rays
Sigmoidoscopy, colonoscopy, and barium enema
CT scans, MRI, ultrasounds

Complications
Toxic megacolon
Perforation
Bleeding vascular engorgement
Highly vascular granulation tissue
Osteoporotic fracture

Inflammatory Bowel Disease

Management:
Nutritional
Pharmacological

5-aminosalicyllic acid
5 ASA sulfa free
Antibiotics
Corticosteroids
Immunosuppressants
Antidiarrheals
Immunomodulators

Inflammatory Bowel Disease

Management
Surgical
Colectomy
Total proctocolectomy with a permanent ileostomy
Postoperative care:
Loose, dark green liquid, with some blood in stool
Pouch system worn at all times
Skin care

Ileostomy (B0x 24-2 p 673-674)

Kock pouch

Question
Which signs symptoms would the nurse expect
to find in a client diagnosed with ulcerative
colitis?
A. 10-20 bloody stools per day
B. Steatorrhea
C. Hard, rigid abdomen
D. Urinary stress incontinence.

Masses in the colon and rectum

Polyps
Neoplastic and Non-neoplastic polyps

Non-neoplastic polyps
Benign epithelial growth occur mostly in large intestine and
small intestine
More common in men and increase with age (50)

Clinical manifestations
Depends on size
Symptoms-rectal bleeding, lower abd pain, obstruction

Nursing management
Removal of polyp and repair as needed

Colorectal Cancer
The third most common cause of cancer deaths
in the United States.
Importance of screening procedures.
Patho

Most colon cancer adenocaricoma

May start as benign polyp
Malignant cells invade and destroy normal tissue
Cancer cells break away from the primary site and
spread to other parts of the body
Most often metastasizes to the liver

Colorectal Cancer
Risk factors

Increasing age (highest in those over 85)

Family hx
Previous colon cancer or polyps
Hx of inflammatory bowel disease
High-fat, low fiber diet, high alcohol consumption,
and smoking

Clinical Manifestations

Change in bowel habits

Blood in stool
Anemia
Anorexia
Weight loss
Fatigue

Colorectal Cancer
Right-Sided Lesions
Dull abdominal pain
Melena

Left sided lesions/associated with obstruction

Bright red blood in stool

Distention
Change in stool (narrow)
Constipation
Abdominal pain and cramping

Rectal lesions
Tenesmus

Rectal pain
Feeling of incomplete evacuation after BM
Constipation alternating with diarrhea
Bloody stool

Diagnostic and Lab

Abdominal and rectal exam

stool for occult blood
Barium enema
Proctosigmoidoscopy
Colonoscopy
Carcioembryonic antigen (CEA)

Nursing management
If intestinal obstruction
IV fluids, NG with suction, blood if needed

TX depends on stage-surgery, supportive therapy, and

adjuvant therapy
chemo-regimen containing 5FU in combination with other
chemo drugs
Radiation may be done before, during, and after surgery
Radiation may be done for palliation
Surgery is primary treatment for colorectal cancersmay be
palliative
Colostomy may be indicated

Complications of colorectal cancer

Partial or complete bowel obstruction

Hemorrhage
Perforation
Abscess formation
Peritonitis
Sepsis
Shock

Colostomies

Complications of elderly
If colostomy indicated:

Decreased vision
Impaired hearing
Difficulty with fine motor movements
Increased potential for skin breakdown
Watch for s/s of decreased blood flow to stoma
Delayed elimination after irrigation
R/t decreased peristalsis and mucus production

Question
The nurse is admitting a client to a medical floor with a
diagnosis of adenocarcinoma of the colon. Which
assessment data support this diagnosis?
A. The client reports up to 20 bloody stools per day.
B. The client has a feeling of fullness after a heavy meal
C. The client has diarrhea alternating with constipation .
D. The client complains of right lower quadrant pain.

Intestinal obstruction
Mechanical: caused by occlusion of the lumen of
the intestinal tract (Figure 24-9 p 678)(Table 24-5 p 679)
Examples: adhesions, hernias, intussusception,
polypoid tumors or neoplasms, stenosis,
strictures, and abscesses

Functional obstruction: impairment of muscle

tone cannot propel the contents and causes a
blockage
Examples: diabetes, neuro disorders, muscular
dystrophy, amyloidosis

Bowel OBS

Most occur in small intestines

May be partial or complete obs
Small bowel obstruction most common cause:

Adhesions
Followed by:

Hernias

Neoplasms

Intrussusception

Volvulus

Large intestine obs occur in sigmoid

Carcinoma
Diverticulitis
IBD

SBO Patho
Fluid, intestinal contents, gas accumulate above
the obstruction
Increased pressure in bowel
Decreased venous and arteriolar pressure
Causes edema and necrosis
Eventually rupture or perforation causing
peritonitis

(SBO) Clinical Manifestations

Crampy, wavelike and colicky pain
Blood or mucous from rectum but no stool or
flatus
Vomiting (fecal vomiting if obs complete)
Abdominal distention
Dehydration
Hypovolemic shock if untreated

Question
A 75-year-old male patient presents at the emergency
department with symptoms of a small bowel obstruction.
An emergency room nurse is obtaining assessment data
from this patient. What assessment finding is
characteristic of a small bowel obstruction?
A. Vomiting
B. Increased urine output
C. Moist mucous membranes
C. Mucus in stool

SBO Diagnostics

Clinical manifestations
Abdominal x-rays
CT scan
Lab- s/s of dehydration

SBO Medical Mgmt

NGT to suction
IV therapy (fluid and electrolyte replacement)
Surgery to remove or treat obs
May remove portion of bowel

SBO Nursing Mgmt

Maintain NGT
Monitoring fluid and electrolyte balance
Assessment of bowel function
Monitor nutritional status
Post-op surgical care

Large Bowel Obs Patho

Similar to SBO
Dehydration occurs more slowly
May not be manifested unless blood supply to
colon is cut off this is life-threatening.
Adenoidcarcinomas are most common cause

Large Bowel OBS

Clinical Manifestations
Symptoms develop and progress slowly
Constipation may be only symptom for months
If located in sigmoid colon or rectum

Stool altered from passing obs

Weakness, wt loss, anorexia
Blood in stool may lead to anemia

Large Bowel OBS

Clinical Manifestations
Vomiting uncommon until advanced-then fecal
vomiting
Abdomen markedly distended
Crampy lower abdominal pain
Fecal vomiting
Symptoms of hypovolemic shock if untreated

Large Bowel OBS

Diagnostic Findings

Clinical manifestations
Abd X-rays
CT scan
MRI
BE is contraindicated

Large Bowel OBS

Medical Mgmt

IV fluid and electrolyte replacement

NGT to suction
Colonoscopy
Cecostomy
Rectal tube
Surgical resection
May require colostomy

Large Bowel OBS

Nursing Mgmt

Monitor s/s
IV fluids and electrolytes
Emotional support
Comfort
If condition does not respond
Surgery
Preop teaching
Post-op care

Anal fistula
Tiny, tubular, fibrous tract that extends into the anal
canal from an opening located beside the anus (Figure
24-10A p 680)
Usually related to infection
Can be from trauma, fissures, or regional enteritis

Symptoms
Pus or stool leaking
May pass flatus or feces from vagina or bladder
Depending on where it is

Can cause systemic infection if untreated

Surgery-fistulectomy always recommended

Most do not heal spontaneoulsy

Anal fissure
Longitudinal tear or ulceration in the anal canal lining (Figure 2410B p680)

Trauma
Passing a large firm stool
Persistent tightening of the anal canal because of stress or anxiety
Childbirth
Trauma
Overuse of laxatives

Symptoms

Painful defecation, burning, bleeding bright red blood on tissue

Treatment-most heal with

Dietary modification fiber supplements, stool softeners, and
bulk agents, increase water intake sitz baths, and emollient
suppositories, anal dilation
Surgery

Hemorrhoids
Dilated portion of veins in the anal canal (Figure
24-10C p680)

Common in those 50 and above

Symptoms
Itching and pain bright red bleeding
Internal hemorrhoids-above internal sphincter
External hemorrhoids-outside of the external sphincter

Treatment
Good personal hygiene and avoid excess straining
Non-surgical
Surgical

Question
Which information does the nurse include when
teaching a patient with new onset hemorrhoids about
prevention and flare ups? Select all that apply.
A. Increase the fiber in your diet to prevent
constipation.
B. Do not participate in any physical exercise.
C. Maintain a healthy weight.
D. Increase your fluid intake.
E. Prolonged sitting or standing will not affect the
development of hemorrhoids.

Sexually Transmitted Anorectal Diseases

Proctitis- involves the rectum

Anal-receptive intercourse with an infected partner

Mucopurulent discharge, bleeding, pain in area, diarrhea

Proctocolitis-involves the rectum and lowers portion of

descending colon
Similar to proctitis and includes watery or bloody
diarrhea, cramps, abdominal tenderness
Enteritis-involves more of the descending colon
Watery, bloody diarrhea, abdominal pain, wt loss

Sigmoidoscopy

Samples and cultures

Treatment

Pilonidal Sinus or Cyst

Found in intergluteal cleft on the posterior surface of the lower
sacrum (Figure 24-11 p 683)
Result from local trauma
Causes penetration of hairs into the epithelium and SQ tissue

May be congenitally formed

Hair protrudes from openings
Rarely causes symptoms until adolescents or early adulthood
when infection
Symptoms
Irritating drainage or abscess

Treatment

Antibiotics
If abscess
Surgery-Abscess incised and drained then further surgery to excise
cyst and secondary sinus tracts

Anorectal disorders
Nursing Management of Patients with Anorectal
conditions (Box 24-3 p 681).

Relieving constipation
Reducing anxiety
Relieving pain
Promoting urinary elimination
Treating patients self-care
Continuing care