chapter 060

Elsevier items and derived items © 2006 by Elsevier Inc.

Interventions for Clients with Noninflammatory Intestinal Disorders

Chapter 60


Irritable Bowel Syndrome (IBS)

• IBS is a chronic gastrointestinal disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating.

• Manning criteria are present:

– Abdominal pain relieved by defecation

– Abdominal distention(Continued)

• IBS is a chronic gastrointestinal disorder characterized by chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating.

• Manning criteria are present:

– Abdominal pain relieved by defecation

– Abdominal distention(Continued)


Irritable Bowel Syndrome (Continued)

– The sense of incomplete evacuation of stool

– The presence of mucus with stool passage

• A flare-up of symptoms usually brings the client to the health care provider.

– The sense of incomplete evacuation of stool

– The presence of mucus with stool passage

• A flare-up of symptoms usually brings the client to the health care provider.


Treatment

• Education—teaching the client to avoid problem stimulants

• Diet therapy—elimination of offending or upsetting foods

• Drug therapy—bulk-forming laxatives, antidiarrheal agents, anticholinergic agents, tricyclic antidepressants, and 5-HT4 agonists.

(Continued)

• Education—teaching the client to avoid problem stimulants

• Diet therapy—elimination of offending or upsetting foods

• Drug therapy—bulk-forming laxatives, antidiarrheal agents, anticholinergic agents, tricyclic antidepressants, and 5-HT4 agonists.

(Continued)


Treatment (Continued)

• Stress management based on the client’s current and ongoing stressors

• Complementary and alternative therapies used to reduce symptoms and discomfort

• Stress management based on the client’s current and ongoing stressors

• Complementary and alternative therapies used to reduce symptoms and discomfort


Herniation

• Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes

• Types of hernia include:

– Indirect inguinal

– Direct inguinal

– Femoral

– Umbilical

– Incisional or ventral

• Weakness in the abdominal muscle wall through which a segment of bowel or other abdominal structure protrudes

• Types of hernia include:

– Indirect inguinal

– Direct inguinal

– Femoral

– Umbilical

– Incisional or ventral


Surgical Management

• Preoperative care—NPO day of surgery

• Operative procedure

– Minimally invasive inguinal hernia repair (MIIHR)

– Conventional herniorrhaphy

(Continued)

• Preoperative care—NPO day of surgery

• Operative procedure

– Minimally invasive inguinal hernia repair (MIIHR)

– Conventional herniorrhaphy

(Continued)


Surgical Management (Continued)

• Postoperative care in minimally invasive inguinal hernia repair includes:

– Elevate scrotum to prevent and control swelling.

– Address difficulties in voiding that may occur.

– Observe for signs and symptoms of complications.

• Postoperative care in minimally invasive inguinal hernia repair includes:

– Elevate scrotum to prevent and control swelling.

– Address difficulties in voiding that may occur.

– Observe for signs and symptoms of complications.


Colorectal Cancer

• Colorectal refers to the colon and the rectum, which together make up the large intestine.

• 95% of cancers of the colon or rectum are adenocarcinomas.

• Etiology

– Genetic considerations

– Personal factors

– Dietary factors

– Inflammatory bowel disease

• Colorectal refers to the colon and the rectum, which together make up the large intestine.

• 95% of cancers of the colon or rectum are adenocarcinomas.

• Etiology

– Genetic considerations

– Personal factors

– Dietary factors

– Inflammatory bowel disease


Clinical Manifestations

• Rectal bleeding, hematochezia, passage of red blood via the rectum

• Anemia

• Change in stool texture

• Mass in abdomen

• Rectal bleeding, hematochezia, passage of red blood via the rectum

• Anemia

• Change in stool texture

• Mass in abdomen


Laboratory Assessment

• Hemoglobin and hematocrit values usually decreased

• Fecal occult blood test

• Possible elevation of carcinoembryonic antigen

• Radiographic assessment

• Other diagnostic assessments

• Hemoglobin and hematocrit values usually decreased

• Fecal occult blood test

• Possible elevation of carcinoembryonic antigen


• Other diagnostic assessments


Anticipatory Grieving Interventions

• Observe and identify:

– Client and family’s current methods of coping

– Effective sources of support in past crises

– Client and family’s present methods of coping

– Signs of anticipatory grieving, such as crying

• Observe and identify:

– Client and family’s current methods of coping

– Effective sources of support in past crises

– Client and family’s present methods of coping

– Signs of anticipatory grieving, such as crying


Potential for Metastasis Interventions

• Treatment based on Dukes’ staging classification

• Radiation therapy

• Drug therapy

– Adjuvant chemotherapy after surgery

– Antiangiogenesis medication

– Monoclonal antibodies and colorectal tumor vaccine (in clinical trials)

• Treatment based on Dukes’ staging classification

• Radiation therapy

• Drug therapy

– Adjuvant chemotherapy after surgery

– Antiangiogenesis medication

– Monoclonal antibodies and colorectal tumor vaccine (in clinical trials)


Surgical Management

• Colon resection

• Colectomy

• Abdominoperineal resection

• Colostomy

• Transanal approach

• Colon resection

• Colectomy

• Abdominoperineal resection

• Colostomy

• Transanal approach


Surgical Management

• Preoperative care includes:

– Consultation with enterostomal therapist

– Discussions with surgeon of risk of sexual and urinary dysfunctions

– Bowel prep

– Nasogastric tube and IV line placed for use after surgery

– Assignment of case manager for long-term consequences

• Preoperative care includes:

– Consultation with enterostomal therapist

– Discussions with surgeon of risk of sexual and urinary dysfunctions

– Bowel prep

– Nasogastric tube and IV line placed for use after surgery

– Assignment of case manager for long-term consequences


Surgical Management

• Postoperative care includes:

– Colostomy and wound management

– Nasogastric tube

– Colostomy management

– Wound management

• Postoperative care includes:

– Colostomy and wound management

– Nasogastric tube

– Colostomy management

– Wound management


Colostomy Care

• Normal appearance of the stoma

• Signs and symptoms of complications

• Measurement of the stoma

• Choice, use, care, and application of appropriate appliance to cover stoma

(Continued)

• Normal appearance of the stoma

• Signs and symptoms of complications

• Measurement of the stoma

• Choice, use, care, and application of appropriate appliance to cover stoma

(Continued)


Colostomy Care (Continued)

• Measures to protect the skin

• Dietary measures to control gas and odor

• Resumption of normal activities

• Measures to protect the skin

• Dietary measures to control gas and odor

• Resumption of normal activities


Intestinal Obstruction

• Mechanical obstruction

• Nonmechanical obstruction, known as paralytic ileus

• Strangulated obstruction resulting from tumors, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis, vascular disorder, and adhesions

• Mechanical obstruction

• Nonmechanical obstruction, known as paralytic ileus

• Strangulated obstruction resulting from tumors, hernias, fecal impactions, strictures, intussusception, volvulus, fibrosis, vascular disorder, and adhesions


Clinical Manifestations of Mechanical Obstruction

• Midabdominal pain or cramping

• Vomiting

• Obstipation

• Diarrhea

• Alteration in bowel pattern and stool

• Abdominal distention

• Borborygmi

• Abdominal tenderness

• Midabdominal pain or cramping

• Vomiting

• Obstipation

• Diarrhea

• Alteration in bowel pattern and stool


• Borborygmi

• Abdominal tenderness


Clinical Manifestations of Nonmechanical Obstruction

• Constant diffuse discomfort


• Decreased to absent bowel sounds

• Vomiting

• Obstipation

• Constant diffuse discomfort


• Decreased to absent bowel sounds

• Vomiting

• Obstipation


Assessment

• Laboratory assessment


• Endoscopy

• Barium enema

• Computed tomography

• Laboratory assessment


• Endoscopy

• Barium enema

• Computed tomography


Nonsurgical Management

• Nothing by mouth

• Nasogastric tube placement

• Nasointestinal tubes

• Fluid and electrolyte replacement

• Pain management

• Drug therapy (e.g., Sandostatin), broad-spectrum intravenous antibiotics

• Nothing by mouth

• Nasogastric tube placement

• Nasointestinal tubes

• Fluid and electrolyte replacement

• Pain management

• Drug therapy (e.g., Sandostatin), broad-spectrum intravenous antibiotics


Surgical Management

• Preoperative care

– Teaching

– Nasogastric intubation and suction if time permits

• Operative procedure: exploratory laparotomy to determine procedure

(Continued)

• Preoperative care

– Teaching

– Nasogastric intubation and suction if time permits

• Operative procedure: exploratory laparotomy to determine procedure

(Continued)


Surgical Management (Continued)

• Postoperative care

– Exploratory laparotomy

– Nasogastric tube in place

– Usual postoperative care

• Postoperative care

– Exploratory laparotomy

– Nasogastric tube in place

– Usual postoperative care


Abdominal Trauma

• Injury to the structures located between the diaphragm and the pelvis, including the large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary bladder

• Blunt abdominal trauma, which often occurs in motor vehicle accidents

• Penetrating abdominal trauma caused by gunshot wounds, stabbing

• Injury to the structures located between the diaphragm and the pelvis, including the large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary bladder

• Blunt abdominal trauma, which often occurs in motor vehicle accidents

• Penetrating abdominal trauma caused by gunshot wounds, stabbing


Assessment

• Assess airway, breathing, and circulation

• Assess for the following:

– Hypovolemic shock

– Cullen’s sign

– Turner’s sign

– Ballance’s sign

– Kehr’s sign

• Assess airway, breathing, and circulation

• Assess for the following:

– Hypovolemic shock

– Cullen’s sign

– Turner’s sign

– Ballance’s sign

– Kehr’s sign


Emergency Care: Abdominal Trauma

• Two large-bore intravenous lines are placed

• Central venous catheter

• Balanced saline solution, crystalloids, and possibly blood

• Arterial blood gas assessment

• Fluid and electrolyte management

• Continuous hemodynamic monitoring

• Surgical management

• Two large-bore intravenous lines are placed

• Central venous catheter

• Balanced saline solution, crystalloids, and possibly blood

• Arterial blood gas assessment

• Fluid and electrolyte management

• Continuous hemodynamic monitoring

• Surgical management


Polyps

• Small growths in the intestinal tract that are covered with mucosa and are attached to the surface of the intestine

• Various types

• Usually asymptomatic, but can cause gross rectal bleeding, intestinal obstruction, and intussusception

• Nursing care focused on teaching

• Small growths in the intestinal tract that are covered with mucosa and are attached to the surface of the intestine

• Various types

• Usually asymptomatic, but can cause gross rectal bleeding, intestinal obstruction, and intussusception

• Nursing care focused on teaching


Hemorrhoids

• Unnaturally swollen or distended veins in the anorectal region

• Internal hemorrhoids

• External hemorrhoids

• Nonsurgical management

• Surgical management: hemorrhoidectomy

• Unnaturally swollen or distended veins in the anorectal region

• Internal hemorrhoids

• External hemorrhoids

• Nonsurgical management

• Surgical management: hemorrhoidectomy


Malabsorption Syndrome

• Syndrome associated with a variety of disorders and intestinal surgical procedures

• Primary clinical manifestations: Diarrhea and steatorrhea

• Interventions:

– Dietary management

– Surgical or nonsurgical management

– Drug therapy

• Syndrome associated with a variety of disorders and intestinal surgical procedures

• Primary clinical manifestations: Diarrhea and steatorrhea

• Interventions:

– Dietary management

– Surgical or nonsurgical management

– Drug therapy

chapter 060

Health & Medicine

stress management

nonsurgical management

abdominal structure

andor abdominal pain

abdominal trauma injury

bowel pattern

absent bowel

segment of bowel