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CHAPTER 56 Care of Patients with Noninflammatory Intestinal Disorders
Terms in this set (84)
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a functional GI disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. It is sometimes referred to as spastic colon, mucous colon, or nervous colon (Fig. 56-1). IBS is the most common digestive disorder seen in clinical practice. In patients with IBS, bowel motility changes and increased or decreased bowel transit times result in changes in the normal bowel elimination pattern to one of these classifications: diarrhea (IBS-D), constipation (IBS-C), alternating diarrhea and constipation (IBS-A), or a mix of diarrhea and constipation (IBS-M). Examples of environmental factors include foods and fluids like caffeinated or carbonated beverages and dairy products. Infectious agents have also been identified. Several studies have found that patients with IBS often have small-bowel bacterial overgrowth, which causes bloating and abdominal distention. Multiple normal flora and pathogenic agents have been identified, including Pseudomonas aeruginosa. Other researchers believe that these agents are less causative and serve as measurable biomarkers. In the United States, women are 2 times more likely to have IBS than are men.
Assessment: Irritable Bowel Syndrome
Ask the patient about a history of weight change, fatigue, malaise, abdominal pain, changes in the bowel pattern (constipation, diarrhea, or an alternating pattern of both) or consistency of stools, and the passage of mucus. Patients with IBS do not usually lose weight. Ask whether the patient has had any GI infections. Collect information on all drugs the patient is taking. Ask about the nutrition history, including the use of caffeinated drinks or beverages sweetened with sorbitol or fructose, which can cause bloating or diarrhea. Food intolerance may be associated with IBS. Dairy products (e.g., for those with lactose intolerance), raw fruits, and grains can contribute to bloating, flatulence (gas), and abdominal distention. Patients may keep a food diary. One of the most common concerns of patients with IBS is pain in the left lower quadrant of the abdomen. Assess the location, intensity, and quality of the pain. Nausea may be associated with mealtime and defecation. The constipated stools are small and hard and are generally followed by several softer stools. The diarrheal stools are soft and watery, and mucus is often present in the stools. Patients with IBS often report belching, gas, anorexia, and bloating.
The patient generally appears well, with a stable weight, and nutritional and fluid status are within normal ranges. Inspect and auscultate the abdomen. Bowel sounds vary. Routine laboratory values (including a complete blood count [CBC], serum albumin, erythrocyte sedimentation rate [ESR], and stools for occult blood) are normal in IBS. Some health care providers request a hydrogen breath test. When small-intestinal bacterial overgrowth or malabsorption of nutrients is present, excess hydrogen is produced. Some of this hydrogen is absorbed into the bloodstream and travels to the lungs where it is exhaled. Patients with IBS often exhale an increased amount of hydrogen.
Teach the patient that he or she will need to be NPO (may have water) for at least 12 hours before the hydrogen breath test. At the beginning of the test, the patient blows into a hydrogen analyzer. Then, small amounts of test sugar are ingested, depending on the purpose of the test, and additional breath samples are taken every 15 minutes for 1 hour
Interventions: Irritable Bowel Syndrome
Interventions include health teaching, drug therapy, and stress reduction. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel elimination habits. The patient should ingest about 30 to 40 g of fiber each day. Eating regular meals, drinking 8 to 10 cups of liquid each day, and chewing food slowly help promote normal bowel function. The health care provider may prescribe bulk-forming or antidiarrheal agents and/or newer drugs to control symptoms. For the treatment of constipation-predominant IBS (IBS-C), bulk-forming laxatives, such as psyllium hydrophilic mucilloid (Metamucil), are generally taken at mealtimes with a glass of water. The hydrophilic properties of these drugs help prevent dry, hard, or liquid stools. Lubiprostone (Amitiza) is an oral laxative approved for women with IBS-C, which increases fluid in the intestines to promote bowel elimination. Teach the patient to take the drug with food and water. Linaclotide (Linzess) is the newest drug for IBS-C, which works by simulating receptors in the intestines to increase fluid and promote bowel transit time. The drug also helps relieve pain and cramping. Teach patients to take this drug once a day about 30 minutes before breakfast. Diarrhea-predominant IBS (IBS-D) may be treated with antidiarrheal agents, such as loperamide (Imodium), and psyllium (a bulk-forming agent). Alosetron (Lotronex), a selective serotonin (5-HT3) receptor antagonist, may be used with caution in women with IBS-D as a last resort. Patients taking this drug must agree to report symptoms of colitis or constipation early because it is associated with potentially life-threatening bowel complications, including ischemic colitis (lack of blood flow to the colon). Many patients with IBS who have bloating and abdominal distention without constipation have success with rifaximin (Xifaxan), an antibiotic that works locally with little systemic absorption. A newer group of drugs called muscarinic-receptor antagonists also inhibit intestinal motility. Some of these agents have been approved for people with overactive bladders but have not yet received FDA approval for IBS. For IBS in which pain is the predominant symptom, tricyclic antidepressants such as amitriptyline (Elavil) have also been successfully used. If patients have postprandial (after eating) discomfort, they should take these drugs 30 to 45 minutes before mealtime.
Before the patient begins alosetron, take a thorough drug (including herbs) history, both prescribed and over the counter, because it interacts with many drugs in a variety of classes. Remind patients that they should not take psychoactive drugs and antihistamines while taking alosetron. Teach patients to report severe constipation, fever, increasing abdominal pain, increasing fatigue, darkened urine, bloody diarrhea, or rectal bleeding as soon as it occurs and stop the drug immediately.
Complementary and Alternative Therapies: Irritable Bowel Syndrome
For patients with increased intestinal bacterial overgrowth, recommend daily probiotic supplements. Probiotics have been shown to be effective for reducing bacteria and successfully alleviating GI symptoms of IBS. Evidence that peppermint oil capsules may be effective in reducing symptoms for patients with IBS. Suggest relaxation techniques, meditation, and/or yoga to help the patient decrease GI symptoms. If the patient is in a stressful work or family situation, personal counseling may be helpful. Teach the patient that regular exercise is important for managing stress and promoting regular bowel elimination.
A hernia is a weakness in the abdominal muscle wall through which a segment of the bowel or other abdominal structure protrudes. Hernias can also penetrate through any other defect in the abdominal wall, through the diaphragm, or through other structures in the abdominal cavity.
The most important elements in the development of a hernia are congenital or acquired muscle weakness and increased intra-abdominal pressure. The most significant factors contributing to increased intra-abdominal pressure are obesity, pregnancy, and lifting heavy objects.
• An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine or omentum. The hernia pushes downward at an angle into the inguinal canal. In males, indirect inguinal hernias can become large and often descend into the scrotum.
• Direct inguinal hernias, in contrast, pass through a weak point in the abdominal wall.
• Femoral hernias protrude through the femoral ring. A plug of fat in the femoral canal enlarges and eventually pulls the peritoneum and often the urinary bladder into the sac.
• Umbilical hernias are congenital or acquired. Congenital umbilical hernias appear in infancy. Acquired umbilical hernias directly result from increased intra-abdominal pressure. They are most commonly seen in people who are obese.
• Incisional, or ventral, hernias occur at the site of a previous surgical incision. These hernias result from inadequate healing of the incision, which is usually caused by postoperative wound infections, inadequate nutrition, and obesity.
A hernia is reducible when the contents of the hernial sac can be placed back into the abdominal cavity by gentle pressure. An irreducible (incarcerated) hernia cannot be reduced or placed back into the abdominal cavity. Any hernia that is not reducible requires immediate surgical evaluation. A hernia is strangulated when the blood supply to the herniated segment of the bowel is cut off by pressure from the hernial ring (the band of muscle around the hernia). If a hernia is strangulated, there is ischemia and obstruction of the bowel loop. This can lead to necrosis of the bowel and possibly bowel perforation. Signs of strangulation are abdominal distention, nausea, vomiting, pain, fever, and tachycardia. Indirect inguinal hernias, the most common type, occur mostly in men because they follow the tract that develops when the testes descend into the scrotum. Direct hernias occur more often in older adults. Femoral and adult umbilical hernias are most common in obese or pregnant women. Incisional hernias can occur in people who have undergone abdominal surgery.
The development of the hernia may be associated with straining or lifting. Perform an abdominal assessment inspecting the abdomen when the patient is lying and again when he or she is standing. If the hernia is reducible, it may disappear when the patient is lying flat. The advanced practice nurse or other health care provider asks the patient to strain or perform the Valsalva maneuver and observes for bulging. Auscultate for active bowel sounds. Absent bowel sounds may indicate obstruction and strangulation, which is a medical emergency! To palpate an inguinal hernia, the health care provider gently examines the ring and its contents by inserting a finger in the ring and noting any changes when the patient coughs. The hernia is never forcibly reduced; that maneuver could cause strangulated intestine to rupture. If a male patient suspects a hernia in his groin, the health care provider has him stand for the examination.
Nonsurgical Management: Herniation
The health care provider may prescribe a truss for an inguinal hernia, usually for men. A truss is a pad made with firm material. It is held in place over the hernia with a belt to help keep the abdominal contents from protruding into the hernial sac. If a truss is used, it is applied only after the physician has reduced the hernia if it is not incarcerated. The patient usually applies the truss upon awakening. Teach him to assess the skin under the truss daily and to protect it with a light layer of powder.
Surgical Management: Herniation
In same-day surgery centers, anesthesia may be regional or general and the procedure is typically laparoscopic. More extensive surgery, such as a bowel resection or temporary colostomy, may be necessary if strangulation results in a gangrenous section of bowel. A minimally invasive inguinal hernia repair (MIIHR) through a laparoscope, also called herniorrhaphy, is the surgery of choice. The most important preoperative preparation is to teach the patient to remain NPO for the number of hours before surgery that the surgeon specifies. If same-day surgery is planned, remind the patient to arrange for someone to take him or her home and be available for the rest of the day. A stool softener may be needed to prevent constipation. Caution patients who are taking oral opioids for pain management to not drive or operate heavy machinery. Teach them to observe incisions for redness, swelling, heat, drainage, and increased pain and promptly report their occurrence to the surgeon. Remind patients that soreness and discomfort rather than severe, acute pain are common after MIS. Teach him or her to avoid strenuous activity for several days before returning to work and a normal routine.
When a hernioplasty is also performed, the surgeon reinforces the weakened outside abdominal muscle wall with a mesh patch.
General postoperative care of patients having a hernia repair is the same as that described in Chapter 16 except that they should avoid coughing. To promote lung expansion, encourage deep breathing and ambulation. The physician may suggest a scrotal support and ice bags applied to the scrotum to prevent swelling, which often contributes to pain. Elevation of the scrotum with a soft pillow helps prevent and control swelling. Encourage men to stand to allow a more natural position for gravity to facilitate voiding and bladder emptying. Urine output of less than 30 mL per hour should be reported to the surgeon. Techniques to stimulate voiding such as allowing water to run may also be used. A fluid intake of at least 1500 to 2500 mL daily prevents dehydration, maintains urinary function, and minimizes constipation.
Surgeons generally allow them to return to their usual activities after surgery, with avoidance of straining and lifting for several weeks while subcutaneous tissues heal and strengthen.
Provide oral instructions and a written list of symptoms to be reported, including fever, chills, wound drainage, redness or separation of the incision, and increasing incisional pain. Teach the patient to keep the wound dry and clean with antibacterial soap and water. Showering is usually permitted in a few days.
Nursing Care of the Postoperative Patient Having a Minimally Invasive Inguinal Hernia Repair (MIIHR)
PG 1148 IGGY
Tumors occur in different areas of the colon, with about two thirds occurring within the rectosigmoid region as shown in Fig. 56-3. Most CRCs are adenocarcinomas, which are tumors that arise from the glandular epithelial tissue of the colon. CRC can metastasize by direct extension or by spreading through the blood or lymph. The tumor may spread locally into the four layers of the bowel wall and into neighboring organs. It may enlarge into the lumen of the bowel or spread through the lymphatics or the circulatory system. The circulatory system is entered directly from the primary tumor through blood vessels in the bowel or via the lymphatic system. The liver is the most common site of metastasis. Colon tumors can also spread by peritoneal seeding during surgical resection of the tumor. Seeding may occur when a tumor is excised and cancer cells break off from the tumor into the peritoneal cavity. For this reason, special techniques are used during surgery to decrease this. Include bowel obstruction or perforation with resultant peritonitis, abscess formation, and fistula formation to the urinary bladder or the vagina. The tumor may invade neighboring blood vessels and cause frank bleeding. Tumors growing into the bowel lumen can gradually obstruct the intestine and eventually block it completely. Those extending beyond the bowel wall may place pressure on neighboring organs (uterus, urinary bladder, and ureters) and cause symptoms that mask those of the cancer.
Etiology and Genetic Risk: Colorectal Cancer
The major risk factors for the development of colorectal cancer (CRC) include being older than 50 years, genetic predisposition, personal or family history of cancer, and/or diseases that predispose the patient to cancer such as familial adenomatous polyposis (FAP), Crohn's disease, and ulcerative colitis. The role of infectious agents in the development of colorectal and anal cancer continues to be investigated. There is also strong evidence that long-term smoking, obesity, physical inactivity, and heavy alcohol consumption are risk factors for colorectal cancer. A high-fat diet, particularly animal fat from red meats, increases bile acid secretion and anaerobic bacteria, which are thought to be carcinogenic within the bowel. Diets with large amounts of refined carbohydrates that lack fiber decrease bowel transit time.
People with a first-degree relative (parent, sibling, or child) diagnosed with colorectal cancer (CRC) have 3 to 4 times the risk for developing the disease. An autosomal dominant inherited genetic disorder known as familial adenomatous polyposis (FAP) accounts for 1% of CRCs. FAP is the result of one or more mutations in the adenomatous polyposis coli (APC) gene. In these very young patients, thousands of adenomatous polyps develop over the course of 10 to 15 years and have nearly a 100% chance of becoming malignant. By 20 years of age, most patients require surgical intervention, usually a colectomy with ileostomy or ileoanal pull-through, to prevent cancer. Chemotherapy may also be used for cancer prevention.
Hereditary nonpolyposis colorectal cancer (HNPCC) is another autosomal dominant disorder and accounts for a small percentage of all colorectal cancers. HNPCC is also caused by gene mutations, including MLH1 and MLH2. People with these mutations have an 80% chance of developing CRC at an average of 45 years of age. They also tend to have a higher incidence of endometrial, ovarian, stomach, and ureteral cancers. Genetic testing is available for both of these familial CRC syndromes. Refer patients for genetic counseling and possible testing if the patient prefers.
Health Promotion and Maintenance: Colorectal Cancer
Those whose family members have had hereditary CRC should be genetically tested for FAP and HNPCC. If gene mutations are present, the person at risk can collaborate with the health care team. Teach people about the need for diagnostic screening. When an adult turns 40 years of age, he or she should discuss with the health care provider the need for colon cancer screening. People of average risk who are 50 years of age and older and without a family history should undergo regular CRC screening. The screening includes fecal occult blood testing (FOBT) and colonoscopy every 10 years or double-contrast barium enema every 5 years. Teach people, regardless of risk, to modify their diets as needed to decrease fat, refined carbohydrates, and low-fiber foods. Encourage baked or broiled foods, especially those high in fiber and low in animal fat. Remind people to eat increased amounts of brassica vegetables, including broccoli, cabbage, cauliflower, and sprouts. These foods help protect the intestinal mucosa from colon cancer.
Teach people the hazards of smoking, excessive alcohol, and physical inactivity.
History: Colorectal Cancer
Ask the patient about major risk factors, such as a personal history of breast, ovarian, or endometrial cancer (which can spread to the colon); ulcerative colitis; Crohn's disease; familial polyposis or adenomas; polyps; or a family history of CRC. Also assess the patient's participation in age-specific cancer screening guidelines. Ask about whether the patient uses tobacco and/or alcohol. Assess the patient's usual physical activity level.
Ask whether vomiting and changes in bowel elimination habits, such as constipation or change in shape of stool with or without blood, have been noted. The patient may also report fatigue (related to anemias), abdominal fullness, vague abdominal pain, or unintentional weight loss. These symptoms suggest advanced disease.
Physical Assessment/Clinical Manifestations: Colorectal Cancer
However, the most common signs are rectal bleeding, anemia, and a change in stool consistency or shape. Stools may contain microscopic amounts of blood that are not noticeably visible, or the patient may have mahogany (dark)-colored or bright red stools. Tumors in the transverse and descending colon result in symptoms of obstruction as growth of the tumor blocks the passage of stool. The patient may report "gas pains," cramping, or incomplete evacuation. Tumors in the rectosigmoid colon are associated with hematochezia (the passage of red blood via the rectum), straining to pass stools, and narrowing of stools. Patients may report dull pain. Right-sided tumors can grow quite large without disrupting bowel patterns or appearance because the stool consistency is more liquid in this part of the colon. These tumors ulcerate and bleed intermittently, so stools can contain mahogany (dark)-colored blood. A mass may be palpated in the lower right quadrant, and the patient often has anemia secondary to blood loss. Examination of the abdomen begins with assessment for obvious distention or masses. Visible peristaltic waves accompanied by high-pitched or "tinkling" bowel sounds may indicate a partial bowel obstruction from the tumor. The examiner may also perform a digital rectal examination to palpate the rectum and lower sigmoid colon for masses.
Psychosocial Assessment: Colorectal Cancer
Patients must cope with a diagnosis that instills fear and anxiety about treatment, feelings that life has been disrupted, a need to search for ways to deal with the diagnosis, and concern about family. They also have questions about why colon cancer affected them, as well as concerns about pain, possible body changes, and possible death. In addition, if the cancer is believed to have a genetic origin, there is anxiety concerning implications for immediate family members.
Laboratory Assessment: Colorectal Cancer
Hemoglobin and hematocrit values are often decreased as a result of the intermittent bleeding. CRC that has metastasized to the liver causes liver enzymes to be elevated. A positive test result for occult blood in the stool (fecal occult blood test [FOBT]) indicates bleeding in the GI tract. Remind the patient to avoid aspirin, vitamin C, and red meat for 48 hours before giving a stool specimen. Also assess whether the patient is taking anti-inflammatory drugs (e.g., ibuprofen, corticosteroids, or salicylates). These drugs should be discontinued for a designated period before the test. Two or three separate stool samples should be tested on 3 consecutive days. Carcinoembryonic antigen (CEA), an oncofetal antigen, is elevated in many people with CRC. The normal value is less than 5 ng/mL.
Imaging Assessment: Colorectal Cancer
A double-contrast barium enema (air and barium are instilled into the colon) or colonoscopy provides better visualization of polyps and small lesions than does a barium enema alone. CT or MRI of the chest, abdomen, pelvis, lungs, or liver helps confirm the existence of a mass, the extent of disease, and the location of distant metastases. CT-guided virtual colonoscopy is growing in popularity and may be more thorough than traditional colonoscopy.
Screening Recommendations for Men and Women Ages 50 Years and Older at Average Risk for Colorectal Cancer
PG 1149 IGGY
Other Diagnostic: Colorectal Cancer
A sigmoidoscopy provides visualization of the lower colon using a fiberoptic scope. A colonoscopy provides views of the entire large bowel from the rectum to the ileocecal valve. As with sigmoidoscopy, polyps can be seen and removed and tissue samples can be taken for biopsy. Colonoscopy is the definitive test for the diagnosis of colorectal cancer.
NANDA-I nursing diagnoses
1. Potential for colorectal cancer metastasis
2. Grieving related to cancer diagnosis (NANDA-I)
Nonsurgical Management: Colorectal Cancer
The administration of preoperative radiation therapy has not improved overall survival rates for colon cancer, but it has been effective in providing local or regional control of the disease. Postoperative radiation has not demonstrated any consistent improvement in survival or recurrence. However, as a palliative measure, radiation therapy may be used to control pain, hemorrhage, bowel obstruction, or metastasis to the lung in advanced disease. Adjuvant chemotherapy after primary surgery is recommended for patients with stage II or stage III disease to interrupt the DNA production of cells and destroy them. Common side effects are diarrhea, mucositis, leukopenia, mouth ulcers, and peripheral neuropathy.
Bevacizumab (Avastin) and panitumumab (Vectibix) are antiangiogenesis drugs, also known as vascular endothelial growth factor (VEGF) inhibitors, approved for advanced CRC. These drugs reduce blood flow to the growing tumor cells, thereby depriving them of necessary nutrients needed to grow.
Cetuximab (Erbitux), a monoclonal antibody known as an epidermal growth factor receptor (EGFR) antagonist, may also be given in combination with other drugs for advanced disease. Intrahepatic arterial chemotherapy, often with 5-FU, may be administered to patients with liver metastasis. Patients with CRC also receive drugs for relief of symptoms, such as opioid analgesics and antiemetics.
Surgical Management: Colorectal Cancer
Surgical removal of the tumor with margins free of disease is the best method of ensuring removal of CRC. Many regional lymph nodes are removed and examined for presence of cancer. The most common surgeries performed are colon resection (removal of the tumor and regional lymph nodes) with reanastomosis, colectomy (colon removal) with colostomy (temporary or permanent) or ileostomy/ileoanal pull-through, and abdominoperineal (AP) resection. A colostomy is the surgical creation of an opening of the colon onto the surface of the abdomen. For patients having a colon resection, minimally invasive surgery (MIS) via laparoscopy is commonly performed today.
Surgical Procedures for Colorectal Cancers in Various Locations
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Preoperative Care: Colorectal Cancer
Reinforce the physician's explanation of the planned surgical procedure. The surgeon may not be able to determine whether a colostomy (or less commonly, an ileostomy) will be necessary. The patient is told that a colostomy is a possibility. The patient who requires low rectal surgery (e.g., AP resection) is faced with the risk for postoperative sexual dysfunction and urinary incontinence after surgery as a result of nerve damage during surgery. Reinforce teaching about abdominal surgery performed for the patient under general anesthesia, and review the routines for turning and deep breathing. Teach the patient about the method of pain management to be used after surgery such as IV patient-controlled analgesia (PCA), epidural analgesia, or other method. The patient may be instructed to thoroughly clean the bowel, or "bowel prep," to minimize bacterial growth and prevent complications. Mechanical cleaning is accomplished with laxatives and enemas or with "whole-gut lavage." Older adults may become dehydrated from this process. To reduce the risk for infection, the surgeon may prescribe one dose of oral or IV antibiotics to be given before the surgical incision is made. Teach patients that a nasogastric tube (NGT) may be placed for decompression of the stomach. A peripheral IV or central venous catheter is also placed for fluid and electrolyte replacement while the patient is NPO after surgery. Patients having minimally invasive surgeries do not need an NGT.
Operative Procedures: Colorectal Cancer
For the conventional open surgical approach, the surgeon makes a large incision in the abdomen and explores the abdominal cavity to determine whether the tumor can be removed. For a colon resection, the portion of the colon with the tumor is excised and the two open ends of the bowel are irrigated before anastomosis (reattachment) of the colon. If an anastomosis is not feasible because of the location of the tumor or the bowel is inflamed, a colostomy is created. A loop stoma (surgical opening) is made by bringing a loop of colon to the skin surface, severing and everting the anterior wall, and suturing it to the abdominal wall. Loop colostomies are usually performed in the transverse colon and are usually temporary. An end stoma is often constructed, usually in the descending or sigmoid colon, when a colostomy is intended to be permanent. The least common colostomy is the double-barrel stoma, which is created by dividing the bowel and bringing both the proximal and distal portions to the abdominal surface to create two stomas.
Postoperative Care: Colorectal Cancer
Patients who have an open colon resection without a colostomy receive care similar to that of those having any abdominal surgery. Other patients have surgeries that also require colostomy management. They typically have a nasogastric tube (NGT) after open surgery and receive IV PCA for the first 24 to 36 hours. After NGT removal, the diet is slowly progressed from liquids to solid foods as tolerated. By contrast, patients who have laparoscopic (MIS) surgery can eat solid foods very soon after the procedure. Because they usually have less pain, they are able to ambulate earlier than those who have the conventional approach.
Colostomy Management: Colorectal Cancer
The patient who has a colostomy may return from surgery with a clear ostomy pouch system in place. A clear pouch allows the health care team to observe the stoma. If no pouch system is in place, a petrolatum gauze dressing is usually placed over the stoma to keep it moist. This is covered with a dry, sterile dressing. In collaboration with the CWOCN, place a pouch system as soon as possible. Assess the color and integrity of the stoma frequently. A healthy stoma should be reddish pink and moist and protrude about 3/4 inch (2 cm) from the abdominal wall (Fig. 56-6). During the initial postoperative period, the stoma may be slightly edematous. A small amount of bleeding at the stoma is common. The colostomy should start functioning in 2 to 3 days postoperatively. When it begins to function, the pouch may need to be emptied frequently because of excess gas collection. It should be emptied when it is one-third to one-half full of stool. Stool is liquid immediately postoperatively but becomes more solid, depending on where in the colon the stoma was placed.
Report any of these problems related to the colostomy to the surgeon:
• Signs of ischemia and necrosis (dark red, purplish, or black color; dry)
• Unusual bleeding
• Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal wall)
Also assess the condition of the peristomal skin (skin around the stoma), and frequently check the pouch system for proper fit and signs of leakage. The skin should be intact, smooth, and without redness or excoriation.
Wound Management: Colorectal Cancer
For an AP resection, the perineal wound is generally surgically closed and two bulb suction drains such as Jackson-Pratt drains are placed in the wound or through stab wounds near the wound. Monitoring drainage from the perineal wound and cavity is important because of the possibility of infection and abscess formation. Serosanguineous drainage from the perineal wound may be observed for 1 to 2 months after surgery. Complete healing of the perineal wound may take 6 to 8 months. The patient may experience phantom rectal sensations because sympathetic innervation for rectal control has not been interrupted. Rectal pain and itching may occasionally occur after healing. Interventions may include use of antipruritic drugs, such as benzocaine, and warm compresses. Continually assess for signs of infection, abscess, or other complications, and implement methods for promoting wound drainage and comfort
Perineal Wound Care
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Assisting with the Grieving Process: Colorectal Cancer
Families and significant others may request that patients not be informed of the diagnosis of cancer, particularly if the patient is an older adult.
Observe and identify:
• The patient's and family's current methods of coping
• Effective sources of support used in past crises
• The patient's and family's present perceptions of the health problem
• Signs of anticipatory grief, such as denial, crying, anger, and withdrawal from usual relationships
Encourage the patient and family to verbalize feelings about the diagnosis, treatment, and anticipated alteration in body functions if a colostomy is planned. Denial, sadness, anger, feelings of loss, and depression are normal responses to this change in body function. Instruct the patient on what to expect about the appearance and care of the colostomy. Postoperatively, encourage him or her to look at and touch the stoma. When the patient is physically able, ask him or her to participate in colostomy care. Participation helps restore the patient's sense of control over his or her lifestyle and thus facilitates improved self-esteem. Assist the patient in identifying the nature of and reaction to the loss. Encourage the patient and family to verbalize feelings and identify fears. Encourage him or her to implement cultural, religious, and social customs associated with the loss, and identify sources of community support. Modifications in lifestyle are needed for patients with CRC. Help the patient and family identify these changes and how best to make them.
Refer patients who are at risk for or have familial CRC for genetic counseling. Specially trained nurses can discuss the purposes and goals of genetic testing. Ensure privacy and confidentiality. A review of the family history may provide important information concerning the pattern of colorectal cancer inheritance. To make an informed decision, the patient and family need information about the advantages, risks, and costs of appropriate genetic tests. Monitor the patient's response regarding genetic risk factors.
Home Care Management: Colorectal Cancer
Assess all patients for their ability for self-management within limitations. For those requiring assistance with care, home care visits by nurses or assistive nursing personnel can be provided. Ostomy products should be kept in an area (preferably the bathroom) where the temperature is neither hot nor cold (skin barriers may become stiff or melt in extreme temperatures) to ensure proper functioning. No changes are needed in sleeping accommodations. A moisture-proof covering may initially be placed over the bed mattress if patients feel insecure about the pouch system. They may consume their usual diet.
Self-Management Education: Colorectal Cancer
Before discharge, teach the patient to avoid lifting heavy objects or straining on defecation to prevent tension on the anastomosis site. If he or she had the open surgical approach, the patient should avoid driving for 4 to 6 weeks while the incision heals. Patients who have had laparoscopy can usually return to all usual activities in 1 to 2 weeks.
A stool softener may be prescribed to keep stools at a soft consistency for ease of passage. Teach patients to note the frequency, amount, and character of the stools. In addition to this information, teach those with colon resections to watch for and report clinical manifestations of intestinal obstruction and perforation (e.g., cramping, abdominal pain, nausea, vomiting). Advise the patient to avoid gas-producing foods and carbonated beverages. Four to six weeks may be required to establish the effects of certain foods on bowel patterns.
Rehabilitation after surgery requires that patients and family members learn how to perform colostomy care. Teach patients and families or other caregivers about:
• The normal appearance of the stoma
• Signs and symptoms of complications
• Measurement of the stoma
• The choice, use, care, and application of the appropriate appliance to cover the stoma
• Measures to protect the skin adjacent to the stoma
• Nutrition changes to control gas and odor
• Resumption of normal activities, including work, travel, and sexual intercourse
Patients with flat, firm abdomens may use either flexible (bordered with paper tape) or nonflexible (full skin barrier wafer) pouch systems. A firm abdomen with lateral creases or folds requires a flexible system. Patients with deep creases, flabby abdomens, a retracted stoma, or a stoma that is flush or concave to the abdominal surface benefit from a convex appliance with a stoma belt. The opening should be large enough not only to cover the peristomal skin but also to avoid stomal trauma. The stoma will shrink within 6 to 8 weeks after surgery. Therefore it needs to be measured at least once weekly during this time and as needed if the patient gains or loses weight. Teach the patient and family caregiver to trace the pattern of the stomal area on the wafer portion of the appliance and to cut an opening. Skin preparation may include clipping peristomal hair or shaving the area (moving from the stoma outward) to achieve a smooth surface, prevent unnecessary discomfort when the wafer is removed, and minimize the risk for infected hair follicles. Advise the patient to clean around the stoma with mild soap and water before putting on an appliance. He or she should avoid using moisturizing soaps to clean the area because the lubricants can interfere with adhesion of the appliance. Control of gas and odor from the colostomy is often an important outcome for patients with new ostomies. Broccoli, beans, spicy foods, onions, Brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, and peas often cause flatus, as does chewing gum, smoking, drinking beer, and skipping meals. Crackers, toast, and yogurt can help prevent gas. Asparagus, broccoli, cabbage, turnips, eggs, fish, and garlic contribute to odor when the pouch is open. Buttermilk, cranberry juice, parsley, and yogurt help prevent odor. Charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch helps eliminate odors. The patient should be cautioned to not put aspirin tablets in the pouch because they may cause ulceration of the stoma. Vents that allow release of gas from the ostomy bag through a deodorizing filter are available. The patient with a sigmoid colostomy may benefit from colostomy irrigation to regulate elimination. However, most patients with a sigmoid colostomy can become regulated through diet.
The Patient with a Colostomy
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Psychosocial Concerns: Colorectal Cancer
The patient's reaction to ostomy surgery may include:
• Fear of not being accepted by others
• Feelings of grief related to disturbance in body image
• Concerns about sexuality
Encourage the patient and family to verbalize their feelings. By teaching how to physically manage the ostomy, help them begin to restore self-esteem and improve body image. Inclusion of family and significant others in the rehabilitation process may help maintain relationships and raise self-esteem. Anticipatory instruction includes information on leakage accidents, odor control measures, and adjustments to resuming sexual relationships.
Intestinal Obstruction 1
In mechanical obstruction, the bowel is physically blocked by problems outside the intestine (e.g., adhesions), in the bowel wall (e.g., Crohn's disease), or in the intestinal lumen (e.g., tumors). Nonmechanical obstruction (also known as paralytic ileus or adynamic ileus) does not involve a physical obstruction in or outside the intestine. Instead, peristalsis is decreased or absent as a result of neuromuscular disturbance, resulting in a slowing of the movement or a backup of intestinal contents. Distention results from the intestine's inability to absorb the contents and move them down the intestinal tract. To compensate for the lag, peristalsis increases in an effort to move the intestinal contents forward. This increase stimulates more secretions, which then leads to additional distention. Plasma leaking into the peritoneal cavity and fluid trapped in the intestinal lumen decrease the absorption of fluid and electrolytes into the vascular space. Reduced circulatory blood volume (hypovolemia) and electrolyte imbalances typically occur. An obstruction high in the small intestine causes a loss of gastric hydrochloride, which can lead to metabolic alkalosis. Obstruction at the end of the small intestine and lower in the intestinal tract causes loss of alkaline fluids, which can lead to metabolic acidosis.
If hypovolemia is severe, renal insufficiency or even death can occur. Bacterial peritonitis with or without actual perforation can also result. However, with closed-loop obstruction (blockage in two different areas) or a strangulated obstruction (obstruction with compromised blood flow), the risk for peritonitis is greatly increased. With a strangulated obstruction, major blood loss into the intestine and the peritoneum can occur. Sepsis and bleeding can result in an increased intra-abdominal pressure (IAP) or acute compartment syndrome.
Intestinal Obstruction 2
Mechanical obstruction can result from:
• Adhesions (scar tissue from surgeries or pathology)
• Benign or malignant tumor
• Complications of appendicitis
• Fecal impactions (especially in older adults)
• Strictures due to Crohn's disease or previous radiation therapy
• Intussusception (telescoping of a segment of the intestine within itself)
• Volvulus (twisting of the intestine)
• Fibrosis due to disorders such as endometriosis
• Vascular disorders (e.g., emboli and arteriosclerotic narrowing of mesenteric vessels)
In people ages 65 years or older, diverticulitis, tumors, and fecal impaction are the most common causes of obstruction.
Postoperative ileus (POI) (paralytic ileus), or nonmechanical obstruction, is most commonly caused by handling of the intestines during abdominal surgery. Electrolyte disturbances, especially hypokalemia, predispose the patient to this problem. The ileus can also be a consequence of peritonitis, because leakage of colonic contents causes severe irritation and triggers an inflammatory response and infection. Vascular insufficiency to the bowel, also referred to as intestinal ischemia, is another potential cause of an ileus. Severe insufficiency of blood supply can result in infarction of surrounding organs (e.g., bowel infarction).
History: Intestinal Obstruction
Collect information about a history of gastrointestinal disorders, surgeries, and treatments. Question the patient about recent nausea and vomiting and the color of emesis. Perform a thorough pain assessment. Severe pain that then stops and changes to tenderness on palpation may indicate perforation and should be reported promptly to the physician. Ask about the passage of flatus and the time, character, and consistency of the last bowel movement. Singultus (hiccups) is common with all types of intestinal obstruction. When an obstruction is suspected, keep the patient NPO and contact the physician. Assess for a family history of colorectal cancer (CRC), and ask about blood in the stool or a change in bowel pattern. Body temperature with uncomplicated obstruction is rarely higher than 100° F (37.8° C). A temperature higher than this, with or without guarding and tenderness, and a sustained elevation in pulse could indicate a strangulated obstruction or peritonitis. A fever, tachycardia, hypotension, increasing abdominal pain, abdominal rigidity, or change in color of skin overlying the abdomen should be reported to the attending physician.
Physical Assessment/Clinical Manifestations: Intestinal Obstruction
The patient with mechanical obstruction in the small intestine often has mid-abdominal pain or cramping. If strangulation is present, the pain becomes more localized and steady. Vomiting often accompanies obstruction and is more profuse with obstructions in the proximal small intestine. The vomitus may contain bile and mucus or be orange-brown and foul smelling as a result of bacterial overgrowth. Prolonged vomiting can result in a disruption in fluid and electrolyte balance. Obstipation (no passage of stool) and failure to pass flatus accompany complete obstruction. Diarrhea may be present in partial obstruction. Mechanical colonic obstruction causes a milder, more intermittent colicky abdominal pain than is seen with small-bowel obstruction. Lower abdominal distention and obstipation may be present, or the patient may have ribbon-like stools if obstruction is partial. Alterations in bowel patterns and blood in the stools accompany the obstruction if colorectal cancer or diverticulitis is the cause. Observe for abdominal distention. Peristaltic waves may also be visible. Auscultate for proximal high-pitched bowel sounds (borborygmi), which are associated with cramping early in the obstructive process as the intestine tries to push the mechanical obstruction forward. In later stages of mechanical obstruction, bowel sounds are absent, especially distal to the obstruction. Abdominal tenderness and rigidity are usually minimal. The presence of a tense, fluid-filled bowel loop mimicking a palpable abdominal mass may signal a closed-loop, strangulating small-bowel obstruction. 1159 In most types of nonmechanical obstruction, the pain is described as a constant, diffuse discomfort. Colicky cramping is not characteristic of this type of obstruction. Pain associated with obstruction caused by vascular insufficiency or infarction is usually severe and constant. On inspection, abdominal distention is typically present. On auscultation of the abdomen, note and document decreased bowel sounds in early obstruction and absent bowel sounds in later stages. Vomiting of gastric contents and bile is frequent, but the vomitus rarely has a foul odor and is rarely profuse. Obstipation may or may not be present.
Chart 56-5 Key Features
Small-Bowel and Large-Bowel Obstructions
PG 1158 IGGY
Diagnostic Assessment: Intestinal Obstruction
White blood cell (WBC) counts are normal unless there is a strangulated obstruction, in which case there may be leukocytosis (increased WBCs). Hemoglobin, hematocrit, creatinine, and blood urea nitrogen (BUN) values are often elevated, indicating dehydration. Serum sodium, chloride, and potassium are decreased. Elevations in serum amylase levels may be found with strangulating obstructions, which can damage the pancreas.
The health care provider obtains an abdominal CT scan as soon as an obstruction is suspected. Distention with fluid and gas in the small intestine with the absence of gas in the colon indicates an obstruction in the small intestine. The health care provider may prescribe an abdominal ultrasound to evaluate the potential cause of the obstruction. The physician may perform endoscopy (sigmoidoscopy or colonoscopy) to determine the cause of the obstruction, except when perforation or complete obstruction is suspected.
Nursing Care of Patients Who Have an Intestinal Obstruction
PG 1159 IGGY
Nonsurgical Management: Intestinal Obstruction
Paralytic ileus responds well to nonsurgical methods of relieving obstruction. Nonsurgical approaches are also preferred in the treatment of patients with terminal disease associated with bowel obstruction. In addition to being NPO, patients typically have a nasogastric tube (NGT) inserted to decompress the bowel by draining fluid and air.Most patients with an obstruction have an NGT unless the obstruction is mild. A Salem sump tube is inserted through the nose and placed into the stomach. It is attached to low continuous suction. Levin tubes do not have a vent and therefore should be connected to low intermittent suction. Question the patient about the passage of flatus, and record flatus and the character of bowel movements daily. Flatus or stool means that peristalsis has returned. Assess for nausea. Monitor any NGT for proper functioning. Assess the patient for nausea, vomiting, increased abdominal distention, and placement of the tube. If the NGT is repositioned or replaced, confirmation of proper placement may be obtained by x-ray. Aspirate the contents and irrigate the tube with 30 mL of normal saline every 4 hours or as requested by the health care provider.
At least every 4 hours, assess the patient with an NGT for proper placement of the tube, tube patency, and output (quality and quantity). Monitor the nasal skin around the tube for irritation. Use a device that secures the tube to the nose to prevent accidental removal. Assess for peristalsis by auscultating for bowel sounds with the suction disconnected (suction masks peristaltic sounds).
Other Nonsurgical Interventions: Intestinal Obstruction
Most types of nonmechanical obstruction respond to nasogastric decompression. Obstruction caused by lower fecal impaction usually resolves after disimpaction and enema administration. Intussusception may respond to hydrostatic pressure changes during a barium enema. For patients with a postoperative ileus (POI), alvimopan (Entereg) may be given for short-term use that increases GI motility. IV fluid replacement and maintenance are indicated for all patients with intestinal obstruction because the patient is NPO and fluid and electrolyte balance is lost (particularly potassium) through vomiting and nasogastric suction. On the basis of serum electrolytes and blood urea nitrogen (BUN) levels, the health care provider prescribes aggressive fluid replacement with 2 to 4 L of normal saline or lactated Ringer's solution with potassium added. Monitor lung sounds, weight, and intake and output daily. Weight is the most reliable indicator of fluid balance. Blood replacement may be indicated in strangulated obstruction because of blood loss into the bowel or peritoneal cavity. Monitor vital signs and other measures of fluid status (e.g., urine output, skin turgor, mucous membranes) every 2 to 4 hours. The physician may prescribe parenteral nutrition (PN). Is usually thirsty, although some older adults have a decreased thirst response. Delegate frequent mouth care to unlicensed assistive personnel (UAP) to help maintain moist mucous membranes. Be sure to supervise this activity. A few ice chips may be allowed if the patient is not having surgery. . The colicky, crampy pain that comes and goes with mechanical obstruction and the nausea, vomiting, dry mucous membranes, and thirst contribute to the patient's discomfort. Continually assess the character and location of the pain, and immediately report any pain that significantly increases or changes from a colicky, intermittent type to a constant discomfort. These changes can indicate perforation of the intestine or peritonitis.
Opioid analgesics may be temporarily withheld in the diagnostic workup period so that clinical manifestations of perforation or peritonitis are not masked. Analgesics such as morphine are given, they may slow intestinal motility and can cause vomiting. Be alert to this side effect because nausea and vomiting are also signs of NG tube obstruction or worsening bowel obstruction. Help the patient obtain a position of comfort with frequent position changes to promote increased peristalsis. A semi-Fowler's position helps alleviate the pressure of abdominal distention on the chest. This position is for comfort and promotion of thoracic excursion to facilitate breathing.
If strangulation is thought to be likely, the health care provider prescribes IV broad-spectrum antibiotics. In addition, in cases of partial obstruction or paralytic ileus, drugs that enhance gastric motility such as octreotide acetate (Sandostatin).
Surgical Management: Intestinal Obstruction
A strangulated obstruction is complete, and surgical intervention is always required. An exploratory laparotomy (a surgical opening of the abdominal cavity to investigate the cause of the obstruction) is initially performed for many patients with obstruction. More specific surgical procedures depend on the cause of the obstruction.
Preoperative Care: Intestinal Obstruction
In cases of complete obstruction, the patient may feel too ill to want the information. Reinforce the information with the family or other caregiver. Depending on the cause and severity of the obstruction, as well as the expertise of the surgeon, patients have either minimally invasive surgery (MIS) via laparoscopy or a conventional open approach.
Operative Procedures: Intestinal Obstruction
In the conventional open surgical approach, the surgeon makes a large incision, enters the abdominal cavity, and explores for obstruction and its cause, if possible (exploratory laparotomy). Obstruction caused by a tumor or diverticulitis requires a colon resection with primary anastomosis or a temporary or permanent colostomy. If obstruction is caused by intestinal infarction, an embolectomy, thrombectomy, or resection of the gangrenous small or large bowel may be necessary. In severe cases a colectomy (removal of the entire colon) may be needed. For the MIS approach, the specially trained surgeon makes several small incisions in the abdomen and places a video camera to view the abdominal contents to determine the extent of the obstruction.
Postoperative Care: Intestinal Obstruction
atients who had an open surgical approach have an NGT in place until peristalsis resumes. A clear liquid diet may be prescribed to encourage peristalsis return. As liquids are started, the NGT can be disconnected from suction and capped for 1 to 2 hours after the patient has taken clear liquids to determine if he or she is able to tolerate them. If the patient vomits after liquids, the suction is resumed. When the patient has return of peristalsis, the NGT suction is discontinued and the tube is clamped for a scheduled amount of time. If the patient does not experience nausea while the NGT is clamped, the tube is removed. With MIS, they usually do not have an NGT and can recover more quickly.
Home Care Management: Intestinal Obstruction
If fecal impaction was the cause of the obstruction, assess the patient's ability to carry out a bowel regimen independently. For those who have had surgery, evaluate their ability to function at home with the added tasks of incision care and possibly colostomy care.
Preventing Fecal Impaction
PG 1161 IGGY
Self-Management Education: Intestinal Obstruction
Instruct the patient to report any abdominal pain or distention, nausea, or vomiting, with or without constipation, because these symptoms might indicate recurrent obstruction. The patient should be reassured, however, that recurrent paralytic ileus is not common.
Teach the patient who has had surgery about incision care, drug therapy, and activity limitations. As with any opioid therapy, an over-the-counter laxative with a softener (e.g., Docusate with Senna) or polyethylene glycol (MiraLax) may be added to prevent constipation and possible recurrent obstruction.
Abdominal trauma is defined as injury to the structures located between the diaphragm and the pelvis that occurs when the abdomen is subjected to blunt or penetrating forces. At least one half of all blunt abdominal traumas occur from motor vehicle crashes. The spleen is the most commonly injured organ from blunt abdominal trauma. Penetrating abdominal trauma is caused by gunshot wounds (GSWs), stabbing, or impalement with an object. The liver is the most commonly injured organ from penetrating abdominal trauma. Trauma is the leading cause of death in adults younger than 40 years in the United States.
Assessment: Abdominal Trauma
First, assess any patient experiencing trauma for airway, breathing, and circulation (ABCs). Inspection of the abdomen may reveal distention. To perform an adequate inspection, turn the patient while maintaining spinal immobilization. Ecchymosis (bruising) may indicate internal bleeding. Ecchymosis present in the distribution of a lap seat belt should be reported to the health care provider immediately because the bowel or other major organ may be injured. Auscultate the abdomen for bowel sounds. Absent or diminished bowel sounds may be caused by the presence of blood, bacteria, or a chemical irritant in the abdominal cavity. Also auscultate for bruits in the abdomen, which could indicate renal artery injury. Injury to the spleen is present in many people with left lower rib fractures. Liver injury may be present in those with right lower rib fractures. Dullness over hollow organs that normally contain gas, such as the stomach and the large and small intestines, may indicate the presence of blood or fluid. Light abdominal palpation identifies areas of tenderness, rebound tenderness, guarding, rigidity, and spasm. A palpated mass may be blood or a fluid collection.
Without obvious significant bleeding or definite signs of peritoneal irritation undergoes abdominal ultrasound, diagnostic peritoneal lavage (DPL), and CT. Abdominal ultrasound or focused abdominal sonography for trauma (FAST) is used to diagnose blunt abdominal trauma and may replace CT and DPL for diagnosis. Patients with hemodynamic instability or peritonitis are candidates for immediate laparotomy.
Once the patient with abdominal trauma has been assessed for airway, breathing, and circulation, focus on the risks for hemorrhage, shock, and peritonitis. Mental status, vital signs, and skin perfusion are priority nursing assessments, with skin perfusion being the most reliable clinical guide in assessing hypovolemic shock:
• In a person with mild shock, the skin is pale, cool, and moist.
• With moderate shock, diaphoresis is more marked and urine output ceases.
• With severe shock, changes in mental status are manifested by agitation, disorientation, and recent memory loss.
Assess for abdominal trauma by asking the patient about the presence, location, and quality of pain. Inspect the abdomen, flanks, back, genitalia, and rectum for contusions, abrasions, lacerations, ecchymosis, penetrating injuries, and asymmetry. All of the patient's clothes must be removed for this examination.
Interventions: Abdominal Trauma
Nonsurgical and surgical interventions are aimed at preserving or restoring hemodynamic stability, preventing or decreasing blood loss, and preventing complications. Patients with abdominal trauma from a vehicle crash often have other injuries such as multiple fractures. The priority for care is to establish and maintain the ABCs.
Emergency Care: Abdominal Trauma
Nursing interventions include placement of at least two large-bore IV catheters in the upper extremities. IV catheters are not used in the lower extremities; if the vasculature has been injured, fluid can pool in the abdomen. IV fluids include saline, crystalloids, and possibly blood. Be sure that the patient is typed and crossmatched for as many as 4 to 8 units of packed red blood cells.
These laboratory values are monitored:
• Arterial blood gases
• Complete blood count (CBC)
• Serum electrolyte, glucose and amylase, and blood urea nitrogen (BUN) determinations
• Liver function tests
• Coagulation studies
Hemoglobin and hematocrit values do not initially reflect true blood loss; values can be skewed because of hemoconcentration from volume loss or the dilutional effects of IV fluids. Serial hemoglobin and hematocrit measurements may be more accurate in determining true blood loss. An elevated white blood cell (WBC) count may indicate a ruptured spleen or intestinal injury. Elevated levels of serum transaminases may indicate liver injury. Elevation of serum amylase activity may signal injury to the pancreas or the bowel. Insert an indwelling urinary (Foley) catheter unless there is blood at the urinary meatus. Initially and hourly thereafter, evaluate urine output for bleeding and specific gravity. Laboratory tests indicate the amount of blood and protein in the urine. If there is an open abdominal wound or evisceration, cover it with a sterile dry dressing unless the physician requests otherwise. Unless it is contraindicated, as in the case of a skull fracture, the physician or nurse inserts a nasogastric tube (NGT) to identify bleeding and minimize the risk for vomiting and aspiration. Antibiotics may be administered.
For the patient who has sustained abdominal trauma, assess for abdominal or referred pain and nausea. Every 15 to 30 minutes in the early postinjury period and then hourly, evaluate:
• Mental status
• Vital signs
• Clinical findings, such as vomiting, guarding, rigidity, or rebound tenderness
• Bowel sounds
• Urine output
Report any change immediately to the health care provider! It is more important to recognize the high risk for an active abdominal injury and assess for general signs of organ injury (e.g., hemorrhage and peritonitis) than to identify the exact nature of the abdominal injury. Opioid analgesics are given for pain after the physician's initial assessment is complete. Explain to the patient and family the rationale for delaying analgesics.
Intra-Abdominal Pressure Monitoring: Abdominal Trauma
The normal IAP in healthy adults is 0 to 5 mm Hg, but obese patients often have a higher normal value. Increased IAP commonly occurs in patients with abdominal trauma. Other causes of IAP elevation include sepsis, burns, abdominal hemorrhage, and mechanical intestinal obstruction. Nursing interventions to help prevent increased IAP in high-risk patients include:
• Record bowel movements.
• Check daily for fecal impaction.
• Provide measures to prevent constipation (e.g., increased fluids if tolerated, daily stool softener).
• Provide fluid replacement with hypertonic saline, crystalloids (e.g., 0.9% saline), or colloids (e.g., albumin, Dextran) as prescribed to expand plasma volume.
• Document intake and output.
• Monitor residuals for patients being tube-fed.
• Elevate the head of the bed to 20-30 degrees, depending on the patient's condition.
• Manage pain adequately.
When IAP becomes higher than the central venous pressure, the inferior vena cava and other abdominal vessels are compressed. The patient is then at risk for deep vein thrombosis and pulmonary embolism (PE). The patient has tachycardia and hypotension. As the IAP increases further, acidosis and ischemia occur. A sustained or repeated IAP of 12 mm Hg or higher is considered intra-abdominal hypertension (IAH). Abdominal acute compartment syndrome (AACS) results when the IAP is sustained at greater than 20 mm Hg. Untreated AACS results in damage to the intestine and increases the risk for sepsis, multiple organ dysfunction syndrome (MODS), and death. The health care provider may request continuous or intermittent IAP monitoring in the critical care unit using a urinary manometer or transducer system. Report any increase in IAP immediately to the health care provider. AACS has a rapid onset after abdominal trauma (especially blunt trauma) and must be treated immediately using either a nonsurgical (vasopressor drugs and fluids) or surgical approach (fasciotomy).
Surgical Management: Abdominal Trauma
The surgeon performs an exploratory laparotomy and repairs abdominal injuries immediately if there are definite signs of peritoneal irritation. These signs include rebound tenderness, significant blood loss, evisceration, or a gunshot wound (GSW) with possible peritoneal involvement. After surgery, many of these patients are admitted to a critical care unit and mechanically ventilated. Most stab wounds and GSWs require exploratory laparotomy. Before discharge from the hospital, teach the patient and family the signs and symptoms of abdominal bleeding whether or not surgery has been performed. Instruct them to report abdominal pain, nausea, vomiting, bloody or black stools, fever, weakness, and dizziness.
Hemorrhage can occasionally occur weeks after blunt abdominal trauma, despite medical evaluation or treatment. For the patient who has surgery or exploration of wounds, provide instructions on wound care before discharge.
Polyps in the intestinal tract are small growths covered with mucosa and attached to the surface of the intestine, and may become malignant. lmost all colorectal cancers develop from an adenoma. Adenomas are further classified as villous or tubular. Of these, villous adenomas pose a greater cancer risk.
Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC) are inherited syndromes characterized by progressive development of colorectal adenomas. Unless these syndromes are treated, colorectal cancer (CRC) inevitably occurs by the fourth to fifth decade of life.
Patient-Centered Collaborative Care: Polyps
Polyps are usually asymptomatic and are discovered during routine colonoscopy screening. However, they can cause gross rectal bleeding, intestinal obstruction, or intussusception (telescoping of the bowel). Biopsy specimens of polyps can be obtained and the entire polyp can be removed (polypectomy). This often eliminates the need for abdominal surgery to remove a suspicious or definitely malignant polyp. The patient with FAP often requires a total colectomy (colon removal) to prevent the development of cancer.
Nursing care focuses on patient education. Instruct the patient about:
• The nature of the polyp
• Clinical manifestations to report to the health care provider
• The need for regular, routine monitoring or screening
If the patient has had a polypectomy, follow-up sigmoidoscopic or colonoscopic examinations are needed because there is an increased risk for developing multiple polyps.
Nursing care of the patient after a polypectomy of the colorectal area includes monitoring for abdominal distention and pain, rectal bleeding, mucopurulent drainage from the rectum, and fever. A small amount of blood might appear in the stool temporarily.
Hemorrhoids are unnaturally swollen or distended veins in the anorectal region. With repeated elevations in pressure from increased intra-abdominal pressure and engorgement from arteriolar shunting of blood, the distended veins eventually separate from the smooth muscle surrounding them. The result is prolapse of the hemorrhoidal vessels. Internal hemorrhoids, which cannot be seen on inspection of the perineal area, lie above the anal sphincter. External hemorrhoids lie below the anal sphincter and can be seen on inspection of the anal region. Hemorrhoids that enlarge, fall down, and protrude through the anus are called prolapsed hemorrhoids. Prolapsed hemorrhoids can become thrombosed or inflamed, or they can bleed. Hemorrhoids are common and not significant unless they cause pain or bleeding. Caused by increased abdominal pressure, the condition worsens during pregnancy, constipation with straining, obesity, heart failure, prolonged sitting or standing, and strenuous exercise and weight lifting. Decreased fluid intake can also cause hemorrhoids because of the development of hard stool and subsequent constipation. Straining while evacuating stool causes them to enlarge.
Health Promotion and Maintenance: Hemorrhoids
Prevention of constipation is the most important preventive measure. It can be prevented by increasing fiber in the diet, such as eating more whole grains and raw vegetables and fruits. Encourage patients to drink plenty of water unless otherwise contraindicated (e.g., kidney disease, heart disease). Remind the patient to avoid straining at stool. Remind him or her to exercise regularly with a gradual buildup in intensity. Maintaining a healthy weight also helps prevent hemorrhoids.
The most common symptoms of hemorrhoids are bleeding, swelling, and prolapse (bulging). Blood is characteristically bright red and is present on toilet tissue or streaked in the stool. Pain is a common symptom and is often associated with thrombosis, especially if thrombosis occurs suddenly. Other symptoms include itching and a mucous discharge. Diagnosis is usually made by inspection and digital examination.
Cold packs applied to the anorectal region for a few minutes at a time beginning with the onset of pain and tepid sitz baths 3 or 4 times per day are often enough to relieve discomfort, even if the hemorrhoids are thrombosed. Topical anesthetics, such as lidocaine (Xylocaine), are useful for severe pain. Dibucaine (Nupercainal) ointment and similar products are available over the counter and may be applied for mild to moderate pain and itching. This ointment should be used only temporarily, however, because it can mask worsening symptoms. If itching or inflammation is present, the health care provider prescribes a steroid preparation, such as hydrocortisone. Cleansing the anal area with moistened cleansing tissues rather than standard toilet tissue helps avoid irritation. The anal area should be cleansed gently by dabbing, rather than by wiping. Diets high in fiber and fluids are recommended to promote regular bowel movements without straining. Stool softeners, such as docusate sodium (Colace), can be used temporarily. Irritating laxatives are avoided, as are foods and beverages that can make hemorrhoids worse. Spicy foods, nuts, coffee, and alcohol can be irritating. Remind patients to avoid sitting for long periods. The health care provider may prescribe mild oral analgesics for pain if the hemorrhoids are thrombosed. The surgeon can perform several procedures in an ambulatory care setting to remove symptomatic hemorrhoids (hemorrhoidectomy). If the hemorrhoid is prolapsed, a circular stapling device may be used to excise a band of mucosa above the prolapse and restore the hemorrhoidal tissue back into the anal canal. Teach patients with hemorrhoids about the need to eat high-fiber, high-fluid diets to promote regular bowel patterns before and after surgery. Advise them to avoid stimulant laxatives. Monitor for bleeding and pain postoperatively and teach them to report these problems to their health care provider. Using moist heat (e.g., sitz baths or warm compresses) 3 or 4 times per day can help promote comfort. Stool softeners such as docusate sodium (Colace) to begin preoperatively and continue after surgery. Analgesics and anti-inflammatory drugs are prescribed. A mild laxative should be administered if the patient has not had a bowel movement by the third postoperative day.
Tell the patient who has had surgical intervention for hemorrhoids that the first postoperative bowel movement may be very painful. Be sure that someone is with or near the patient when this happens. Some patients become light-headed and diaphoretic and may have syncope ("blackout").
It interferes with the ability to absorb nutrients and is a result of a generalized flattening of the mucosa of the small intestine. With various disorders, physiologic mechanisms limit absorption of nutrients because of one or more of these abnormalities:
• Bile salt deficiencies
• Enzyme deficiencies
• Presence of bacteria
• Disruption of the mucosal lining of the small intestine
• Altered lymphatic and vascular circulation
• Decrease in the gastric or intestinal surface area
The nutrient involved in malabsorption depends on the type and location of the abnormality in the intestinal tract.
Deficiencies of bile salts can lead to malabsorption of fats and fat-soluble vitamins. Bile salt deficiencies can result from decreased synthesis of bile in the liver, bile obstruction, or alteration of bile salt absorption in the small intestine. Lactase deficiency is the most common disaccharide enzyme deficiency. Without sufficient amounts of this enzyme, the body is not able to break down lactose. Deficiencies of the other disaccharide enzymes are rare. Pancreatic enzymes are also necessary for absorption of vitamin B12. With destruction or obstruction of the pancreas or insufficient pancreatic stimulation, this nutrient is not well absorbed. Chronic pancreatitis, pancreatic carcinoma, resection of the pancreas, and cystic fibrosis can cause these malabsorption problems. Loops of bowel can accumulate intestinal contents, resulting in bacterial overgrowth, when peristalsis is decreased. Bacteria at these sites break down bile salts, and fewer salts are available for fat absorption. They can also ingest vitamin B12, which contributes to vitamin B12 deficiency. Obstruction to lymphatic flow in the intestine can lead to loss of plasma proteins along with loss of minerals (e.g., iron, copper, calcium), vitamin B12, folic acid, and lipids. Lymphatic obstruction can be caused by many conditions. Interference with blood flow to the intestinal mucosa results in malabsorption. With intestinal surgery, there is loss of the surface area needed to facilitate absorption. Resection of the ileum results in vitamin B12, bile salt, and other nutrient deficiencies. Gastric surgery is one of the most common causes of malabsorption and maldigestion.
Assessment: Malabsorption Syndrome
Chronic diarrhea is a classic symptom of malabsorption. It occurs as a result of unabsorbed nutrients, which add to the bulk of the stool, and unabsorbed fat. Steatorrhea (greater than normal amounts of fat in the feces) is a common sign. It is a result of bile salt deconjugation, nonabsorbed fats, or bacteria in the intestine. Some have an increased stool mass. Other clinical manifestations include:
• Unintentional weight loss
• Bloating and flatus (carbohydrate malabsorption)
• Decreased libido
• Easy bruising (purpura)
• Anemia (with iron and folic acid or vitamin B12 deficiencies)
• Bone pain (with calcium and vitamin D deficiencies)
• Edema (caused by hypoproteinemia)
Serum laboratory studies reveal a decrease in mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC). These decreases indicate hypochromic microcytic anemia resulting from iron deficiency. Increased MCV and variable MCH and MCHC values indicate macrocytic anemia resulting from vitamin B12 and folic acid deficiencies. Serum iron levels are low in protein malabsorption because of insufficient gastric acid for use of iron. Serum cholesterol levels may be low from decreased absorption and digestion of fat. Low serum calcium levels may indicate malabsorption of vitamin D and amino acids. Low levels of serum vitamin A (retinol) and carotene, its precursor, indicate a bile salt deficiency and malabsorption of fat. Serum albumin and total protein levels are low if protein is lost.
A quantitative fecal fat analysis is often elevated in either malabsorption or maldigestive disorders.
A lactose tolerance test is a type of disaccharidase analysis that may show an inability to digest foods and beverages that contain lactose. A hydrogen breath test can also be performed to detect 1166this problem. The d-xylose absorption test can reveal low urine and serum d-xylose levels if malabsorption in the small intestine is present.
The Schilling test measures urinary excretion of vitamin B12 for diagnosis of pernicious anemia and a variety of other malabsorption syndromes. The bile acid breath test assesses the absorption of bile salt. If the patient has bacterial overgrowth, the bile salts will become deconjugated and the carbon dioxide level in the breath will peak earlier than expected.
Ultrasonography is used to diagnose pancreatic tumors and tumors in the small intestine that are causing malabsorption. X-rays of the GI tract reveal pancreatic calcifications, tumors, or other abnormalities that cause malabsorption. A CT scan may also be done.
Interventions: Malabsorption Syndrome
Interventions for most malabsorption syndromes focus on (1) avoidance of substances that aggravate malabsorption and (2) supplementation of nutrients.
Nutrition management includes a low-fat diet for patients who have gallbladder disease, severe steatorrhea, or cystic fibrosis. A low-fat diet may or may not be indicated for pancreatic insufficiency because this disorder improves with enzyme replacement. Some clinicians believe that limitation of fat intake is not necessary with enzyme replacement. Dietary intake of fat is actually beneficial to the patient because it has a high number of calories. After a total gastrectomy, a high-protein, high-calorie diet and small, frequent meals are recommended. Lactose-free or lactose-restricted diets are available as well as gluten-free. The health care provider prescribes nutritional supplements according to the specific deficiency. Common supplements include:
• Water-soluble vitamins, such as folic acid and vitamin B complex
• Fat-soluble vitamins, such as vitamin A, vitamin D, and vitamin K
• Minerals, such as calcium, iron, and magnesium
• Pancreatic enzymes, such as pancrelipase (Pancrease, Viokase)
Antibiotics are used to treat disorders involving bacterial overgrowth. Bacterial overgrowth can be caused by a variety of disorders but is often treated with tetracycline and metronidazole (Flagyl, Novonidazol).
Drug therapy is used to control the clinical manifestations of malabsorption. Antidiarrheal agents, such as diphenoxylate hydrochloride and atropine sulfate (Lomotil, N-Lomotil image), are often used to control diarrhea and steatorrhea. Anticholinergics, such as dicyclomine hydrochloride (Bentyl, Bentylol image), may be given before meals to inhibit gastric motility. IV fluids may be necessary.
Provide special measures to protect the skin when chronic diarrhea occurs.
Special Skin Care for Patients with Chronic Diarrhea
PG 1166 IGGY
What might you NOTICE if the patient has impaired absorption and inadequate nutrition as a result of noninflammatory intestinal disorders?
• Rectal bleeding
• Report of change in bowel habits
• Diarrhea or report of constipation
• Abdominal pain
• Change in bowel sounds (decreased or increased)
• Weight loss
Perform and interpret focused physical assessment findings, including:
• Vital signs
• Complete pain assessment
• Abdominal assessment
• Current weight compared with previous weight
• Decreasing abdominal pain by placing patient in sitting position
• Starting IV (large-bore catheter) to replace fluids and electrolytes
• Giving blood transfusion as prescribed
• Providing rest
• Providing privacy and dignity
• Assisting with hygiene as needed
• Inserting nasogastric tube and connecting to low suction as needed
• Checking laboratory values of hemoglobin and hematocrit
• Checking stool for occult or frank blood
• Giving antidiarrheal drugs if prescribed
• Recording intake and output
• Assisting with ADLs and ambulation as needed
Key Points: Safe and Effective Care Environment
• Prioritize care for patients experiencing abdominal trauma: first assess airway, breathing, and circulation (ABCs), and then monitor vital signs, mental status, and skin perfusion to assess for hypovolemic shock.
• Collaborate with the certified wound, ostomy, continence nurse (CWOCN) or enterostomal therapist (ET) when a patient is scheduled for or has a new colostomy.
• Collaborate with the case manager/discharge planner, health care provider, and CWOCN to plan care for the patient with CRC.
Key Points: Health Promotion and Maintenance
• Refer patients with familial CRC syndromes for genetic counseling and testing.
• Refer ostomy patients to the United Ostomy Associations of America, Inc. and the American Cancer Society for additional information and support groups.
• Teach patients with irritable bowel syndrome (IBS) to avoid GI stimulants, such as caffeine, alcohol, and milk and milk products, and to manage stress.
• Instruct patients on dietary modifications to decrease the occurrence of colorectal cancer (CRC), such as eating a diet high in fiber and avoiding red meat.
• Teach adults 50 years and older to have routine screening for CRC as listed in Chart 56-2; people with genetic predispositions should have earlier and more frequent screening.
• Teach people to prevent or manage constipation to help avoid hemorrhoids; teach patients the importance of maintaining a healthy weight to decrease the risk for hemorrhoids. Evidence-Based Practice image
• Teach patients and caregivers how to provide colostomy care, including dietary measures, skin care, and ostomy products.
Key Points: Psychosocial Integrity
• Assist the patient with CRC with the grieving process.
• Be aware that having a colostomy is a life-altering event that can severely impact one's body image; issues related to sexuality and fear of acceptance should be discussed.
Key Points: Physiological Integrity
• Be aware that minimally invasive inguinal hernia repair is an ambulatory care procedure done via laparoscopy; postoperative management requires health teaching regarding rest for a few days and inspection of incisions for signs of infection (see Chart 56-1).
• Be aware that a strangulated hernia can cause ischemia and bowel obstruction, requiring immediate intervention.
• Monitor patients who have conventional open herniorrhaphy for ability to void.
• Recall that changes in bowel habits or stool characteristics and/or rectal bleeding are often associated with a diagnosis of CRC.
• Keep the peristomal skin clean and dry; observe for leakage around the pouch seal.
• Provide meticulous perineal wound care for patients having an abdominoperineal (AP) resection, as described in Chart 56-3.
• Document the characteristics of the colostomy stoma, which should be reddish pink and moist; report abnormalities such as ischemia and necrosis (purplish or black) or unusual bleeding to the surgeon.
• Recall that bowel sounds are altered in patients with obstruction; absent bowel sounds imply total obstruction. Safety image• Assess the patient's nasogastric tube for proper placement, patency, and output at least every 4 hours.
• Monitor patients with bowel obstruction for signs and symptoms of fluid, electrolyte, and acid-base imbalances; patients with small bowel obstruction are at greater risk for problems with fluid and electrolyte balance.
• Teach patients having hemorrhoid surgery to take stool softeners before and after surgery to decrease discomfort during elimination.
• Provide comfort measures for the patient who has chronic diarrhea associated with malabsorption as described in Chart 56-8.
• Reinforce teaching regarding supplements or dietary restrictions needed for malabsorption management.
THIS SET IS OFTEN IN FOLDERS WITH...
CHAPTER 57 Care of Patients with Inflamm…
CHAPTER 55 Care of Patients with Stomach Disorders
CHAPTER 54 Care of Patients with Esophag…
CHAPTER 52 Assessment of the Gastrointestinal Syst…
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