Intestinal Obstructions partial or complete obstruction of the forward flow of intestinal contents most obstructions occurs in the small

bowel

 Etiology/ Risk Factors: Narrowing of the lumen due to inflammation, neoplasm, adhesions, hernia, volvulus, intussusception, food blockage, or compression from outside the intestine.

 Mechanical Factors: Hernia- incarcerated hernia may or may not cause obstruction, depending on the size of the hernial ring. A strangulated hernia is always obstructed, because the bowel cannot function when its blood supply is cut off. Intussusception- telescoping of the bowel Often associated with tumor of the large bowel. Peristaltic action telescopes the proximal bowel to the bowel distal to it. Intramural lesions often cause intussusception.

Volvulus- twisting of the bowel that frequently occurs about a stationary focus (e.g., tumor or Meckels diverticulum) in the abdominal cavity. Cause infection of the bowel and can occur either at the large or small bowel Can sometimes be corrected without surgery Successful decompression of the bowel using a long tube (Cantor or Miller-Abbot tube) releases pressure against the proximal end of the loop, thus allowing a small bowel volvulus to relax

 Adhesion- most common cause of obstruction in the large and small intestine

 Tumors- chief cause of obstruction in the large bowel

Question
Situation 7: Mr. Sean is admitted to the hospital with a bowel obstruction. He complained of colicky pain and inability to pass stool. Nasogastric tube was inserted to Mr. Sean. The NGTs primary purpose is: a. nutrition b. decompression of bowel c. passage for medication d. aspiration of gastric contents

Question
Mr. Sean has undergone surgery. Post operatively, which of the following findings is normal? a. absent bowel sounds b. bleeding c. hemorrhage d. bowel movement

Question
Client education should be given in order to prevent constipation. Nurse Leonards health teaching should include which of the following? a. use of natural laxatives b. fluid intake of 6 glasses per day c. use of OTC laxatives d. complete bed rest

 Assessment: complete history of onset of manifestations, eating patterns, food tolerance, vomiting episodes, stools, distention, and factors that increase or decrease pain physical assessment: abdominal distention, quality of bowel sounds, presence and extent of dehydration, muscle guarding or manifestation of

 Manifestations of intestinal obstruction depend on the following: The level and length of bowel involved. The degree to which the obstruction interferes with the blood supply. The completeness of the obstruction. The type of lesion producing the obstruction

 Local effects in the bowel wall: caused by the following: Loss of fluids, electrolytes, plasma Bacterial proliferation Perforation Congestion Fragility Reduced circulation Increased pressure, which leads to reverse peristalsis (producing vomiting that helps prevent over distention of the bowel)

 Systemic effects include the following: Reduced extracellular fluids and circulating blood volume Toxemia Peritonitis

 General Manifestations: abdominal pain in rhythmically recurring waves small intestinal pain- felt in upper and mid-abdomen colonic pain- felt in the lower abdomen visible peristaltic waves with accompanying high-pitch tinkling sounds nausea and vomiting hypoxia, in severe abdominal distention electrolyte imbalance intussusception: currant jelly-like stools, sausage-like mass on abdomen

 Diagnostic Exams: Plain Film- shows gas shadows Barium or radiopaque x-ray studies Increased Hemoglobin and Hematocritindicates dehydration Leukocytosis- may signify strangulated bowel decreased sodium, potassium, and chloride levels accompanied by a rise in nonprotein nitrogen and BUN levels may indicate small bowel obstruction

 Nursing Diagnosis: Fluid Volume Deficit related to vomiting, decreased intestinal reabsorption of fluid, and decreased intestinal secretions.

 Nursing Interventions: Maintain good fluid balance. Administer parenteral fluids with sodium, potassium, chloride, and bicarbonate added, as ordered. Maintain intestinal tube attached to suction to relieve vomiting and distention. Assist in surgical management to treat bowel obstruction (bowel resection, colostomy, bypass procedure). Give client teaching of ways to prevent recurrence and maintain bowel elimination. Monitor clients nutritional status.

 Hirschsprungs disease also known as Congenital Aganglionic Megacolon congenital anomaly functional obstruction of the colon caused by lack of nerve cells in the colon walls resulting to absence of peristalsis. More common in boys, and among with Down syndrome familial tendency mechanical bowel obstruction

 A newborns failure to pass meconium within 24 hours after birth may indicate which of the following? a. Aganglionic Mega colon b. Celiac disease c. Intussusception d. Abdominal wall defect

Assessment Signs and Symptoms: Newborn- (-) meconium with in 24 hours Infants- chronic constipation Children- ribbon-like stools Vomiting bile-stained or fecal material Obstipate constipation (inability to pass out stool without softeners, laxatives) Visible peristalsis, palpable fecal mass Ribbon-like stool Abdominal distention Nutrient malabsorption

 Diagnostic Exams:
Rectal biopsy Barium enema

Management Surgery: Colectomy- removal of affected colon Temporary colostomy

 Pre-operative Care
Monitor abdominal girth, daily weight, Intake and output, urine specific gravity Promote optimal nutritional and fluid status Gastric decompression: low suction via NGT Semi-fowlers position Isotonic saline enema to cleanse the bowel No rectal temperature

 Post-operative Care
Teach parents about colostomy care Accurate recording of stools (number, frequency, consistency) Educate on second-stage repair Routine Post-operative care for abdominal surgeries

Question
A nurse is giving instructions to a 66-year-old client with a new colostomy. The client states, "I am so tired today; I just cannot think." The nurse should: Reschedule the appointment at a time when the client is rested. Give the client a written instruction sheet instead of verbal teaching. Ask the client to concentrate because the instructions are important. Give the teaching session to the spouse instead of the client.

Imperforate Anus Imperforate anus is congenital (present from birth) defect in which the opening to the anus is missing or blocked.

 Assessment:
Swollen belly area or abdominal enlargement Anal opening very near the vaginal opening in girls Missing or misplaced opening to the anus No passage of first stool within 24 - 48 hours after birth Stool passes out of the vagina, base of penis, scrotum, or urethra

 Diagnostic test:
Plain radiograph of the abdomen to locate the lesion Ultrasound of the perineum determine the distance between a meconium-filled distal rectum and a finger on the perineum

 Management:
perineal anoplasty pull through operation with or without colostomy With a high imperforate anus, a colostomy (to divert the path of stool) is usually done..

 Hemorrhoids
dilated blood vessels beneath the lining of the skin in the anal canal

 Types:
External hemorrhoid- occur below the anal sphincter Internal hemorrhoid- occur above the anal sphincter

 Cause/ Etiology:
Chronic constipation Pregnancy Obesity Prolonged sitting or standing Wearing constrictive clothing Disease conditions like liver cirrhosis, Ride-sided CHF

 Assessment: Constipation in an effort to prevent pain or bleeding with defecation Anal pain Rectal bleeding Anal itchiness Mucous secretion from the anus Sensation of incomplete evacuation of the rectum Internal hemorrhoids may prolapse

 Nursing Diagnosis:
Constipation related to pain sensation during defecation

 Collaborative Management:
High fiber diet with liberal fluid intake Bulk laxatives Hot sitz bath, warm compress Local anesthetic applicationNupercaine

 Surgery:
Hemorhoidectomy Sclerotherapy (5% phenol in oil) Cryosurgery Rubber-band ligation

 Pre-operative care:
Low residue diet to reduce the bulk of stool Stool softener

 Post-operative care:
Promotion of Comfort
Analgesics as required Side-lying position Hot sitz bath 12- 24 hours post-operatively

Promotion of elimination
Stool softener as prescribed Encourage the client to defecate as soon as the urge occurs Analgesic before the initial defecation Enema as prescribed, using a small-bore rectal tube

 Patient teaching
Clean rectal area thoroughly after each defecation Sitz bath at home especially after each defecation

Avoid constipation:
High-fiber diet High fluid intake Regular exercise Regular time for defecation

 Use stool softener until healing is complete Notify physician of the following: Rectal bleeding Suppurative drainage Continued pain on defecation Continued constipation

Question
Nurse Nico is caring to a 38-year-old female, G3P3 client who has been diagnosed with hemorrhoids. Which of the following factors would most likely be a primary cause of her hemorrhoids? a. Her age b. Three vaginal delivery pregnancies c. Her job as a school teacher d. Varicosities in the legs

Question
Client education should include minimizing client discomfort due to hemorrhoids. Nursing management should include: a. Suggest to eat low roughage diet b. Advise to wear silk undergarments c. Avoid straining during defecation d. Use of sitz bath for 30 minutes

Question
Nurse Nico instructs her client who has had a hemorrhoidectomy not to used sitz bath until at least 12 hours postoperatively to avoid which of the following complications? a. Hemorrhage b. Rectal Spasm c. Urinary retention d. Constipation

 Celiac Disease
Gluten intolerance an immune system disorder that results in damage to the lining of the small intestine when foods with gluten are eaten

Also called celiac sprue, glutensensitive enteropathy, nontropical sprue Unknown cause Gluten is a form of protein found in some grains- notably barley, rye, oats, wheat (BROW)

 Manifestations: May include one or more of the following:

gas recurring abdominal bloating and pain chronic diarrhea constipation

pale, foul-smelling, or fatty stool weight loss/weight gain fatigue unexplained anemia (a low count of red blood cells causing fatigue) bone or joint pain osteoporosis, osteopenia behavioral changes

tingling numbness in the legs (from nerve damage) muscle cramps seizures missed menstrual periods (often because of excessive weight loss)

infertility, recurrent miscarriage delayed growth failure to thrive in infants pale sores inside the mouth, called aphthous ulcers

tooth discoloration or loss of enamel itchy skin rash called dermatitis herpetiformis

 Laboratory Exams:
serum antibodies abdominal x-ray endoscopy stool exam

 Nursing diagnosis:
Altered Nutrition: Less than body requirements related to decreased absorptive ability of the small intestine

 Nursing Management;
only treatment for Celiac disease is a gluten-free diet assist patient and family in implementing a gluten-free diet

provide health teachings on the importance of strictly adhering to prescribed diet provide a list of gluten containing food and common gluten-free food.

 Chronic Inflammatory Bowel Disease

used to identify two chronic gastrointestinal disorders: regional enteritis (i.e. Crohns disease) and ulcerative colitis

 Etiology:
Both are characterized by exacerbations and remissions. Exacerbations may be triggered by pesticides, food additives, tobacco, radiation exposure, and immunologic influences. Hereditary predisposition.

 Regional enteritis (i.e. Crohns disease)- subacute and chronic inflammation that extends through all layers of the bowel wall from the intestinal mucosa. Fistula, fistures, and abscesses extend into the peritoneum, but segments of normal intestinal tissue occur between the inflammation.

 Ulcerative Colitis- inflammatory disease of the submucosal layer of the colon and rectum characterized by continuously occurring ulcerations and shedding of intestinal epithelium. Fat deposits and muscular hypertrophy result in a narrow, short, and thickened bowel.

Assessment findings: Clinical Manifestations:

Regional enteritis
Abdominal tenderness and pain, typically colicky and increased after meals Diarrhea, flatulence, and steatorrhea

 Fever, malaise, anorexia Signs of nutritional deficits Perianal fistulas and abscesses Usually occurs in ileum and ascending colon

Ulcerative Colitis Severe diarrhea containing pus, blood, and mucus Abdominal cramping and tenderness, fever Anorexia and weight loss Usually occurs in the descending colon and rectum

 Laboratory and diagnostic study findings

Regional enteritis
Barium study of the upper GIT, the most conclusive test,

 Barium enema Colonoscopy CT scan

Ulcerative colitis
Barium enema

 Colonoscopy shows friable mucosa with pseudopolyps or ulcers in the descending colon and sigmoid colon. Stool analysis is positive for blood. Entamoeba histolytica, which causes dysentery, must be ruled out.

 Nursing Diagnosis:
Altered nutrition: less than body requirements related to malabsorption of nutrients Diarrhea related to inflamed intestinal mucosa Altered Comfort: Acute Pain related to inflamed intestinal mucosa

 Nursing Management;
Administer medicationsantidiarrheals, corticosteroids, antibiotics, antispasmodics, anticholinergic, and narcortic analgesics

Enhance nutritional status: Promote nursing care for the client who is on NPO, receiving oral fluids, or on total parenteral nutrition during acute exacerbation. Assess for fluid and electrolyte imbalance.

 Encourage low-residue, highprotein, high-calorie diet with supplemental vitamin therapy and iron replacement. Implement measures to treat diarrhea or constipation.

 Minimize pain- intermittent rest periods and bed rest when client is in acute exacerbations. Promote client and family coping.

Provide health teachings on the importance of good nutrition and adequate fluid intake, stress management techniques, perianal skin care, and the need for follow-up visit to the physician.

Provide appropriate preoperative and post-operative care, if surgery is indicated.

Colectomy with colostomy

 Diverticulitis and Diverticulosis

Diverticulum is outpouching of the mucosal lining of the GIT, commonly in the colon Diverticulosis- multiple outpouchings without inflammation Diverticulitis- acute inflammation and infection
caused by trapped fecal material and bacteria.

 Assessment
Crampy lower left quadrant abdominal pain worsens with movement, coughing, or straining Low-grade fever Chronic constipation with episodes of diarrhea Nausea and vomiting Abdominal distention and tenderness Occult bleeding Signs and symptoms of peritonitis due to development of abscess or perforation Diverticulosis- asymptomatic, multiple diverticula are present without inflammation

 Laboratory and diagnostic study findings:

CBC may reveal elevated WBC and ESR. Colonoscopy Barium enema

 Collaborative Management
High fiber diet Liberal fluid intake of 2,500 to 3,000 ml/day Inform client that all nursing interventions are aimed at moving the stools through the colon easily and with as little irritation as possible. Avoid nuts and seeds which can become trapped in the diverticula Prevent constipation Bulk-forming laxatives weight loss to reduce intra-abdominal pressure

 During an acute episode: Bed rest NPO, then clear liquids to rest the bowel Avoid high fiber foods to prevent further irritation of the mucosa IVFs, antibiotics, analgesics, anticholinergics NGT insertion to relive distention

Question
Which of the following definitions best describes diverticulosis? a. An inflamed outpouching of the intestine b. A non inflamed outpouching of the intestine c. The partial impairment of the forward flow of instestinal contents d. An abnormal protrusions of an oxygen through the structure that usually holds it

Question
To improve Mr. Trinidads condition, your best nursing intervention and teaching is: a. Reduce fluid intake b. Increase fiber in the diet c. Administering of antibiotics d. Exercise to increase intraabdominal pressure