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CHAPTER 56 Care of Patients with Noninflammatory Intestinal Disorders

Terms in this set (84)

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 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.
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.
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.
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.
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.
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.
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.
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).
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.
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.
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).
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.
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.
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 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.
• 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.