GASTRO-INTESTINAL SYSTEM Inform client that the stool is white for 24 –

72 hours
DIAGNOSTIC TESTS  Observe for Ba impaction : distended
Laboratory Tests abdomen, constipation
1. CEA ( Carcinoembryonic Antigen) 3. LGIS (Ba Enema)
 (+) colorectal Ca  To visualize the colon
 X heparin for 2 days  Low residue / clear liquid diet for 2 days
 Specimen by venipuncture  Laxative for cleansing the bowel
 Suppository / cleansing enema in A.M.
2. Exfoliative Cytology  BaSO4 per rectum
 Detect malignant cells  Care after the procedure – same as UGIS
 Written consent ENDOSCOPY
 Liquid diet
 UGI : NGT insertion 1. UGI Endoscopy
 LGI : laxative; enema  Direct visualization of esophagus, stomach, and
 Cells are obtained from saline duodenum
 Lavage – NGT / Proctoscope  Obtain written consent
 NPO for 6 – 8 hours
3. Stool for Occult Blood (Guaiac Stool Exam)  Anticholinergic (AtSO4) as ordered
 Detect G.I. Bleeding  Sedatives, narcotics, tranquilizers
 High fiber diet 48 – 72 hours  E.g. Diazepam, Meperidine HCl
 X red meats, poultry, fish, turnips,  Remove dentures, bridges
horseradish  Local spray anesthetic on posterior pharynx –
 Withold for 48 hrs: Iron, Steroids, instruct : X swallow saliva
Indomethacine, Colchicine  After the procedure
 3 stool specimen ( 3 successive days)  Side – lying position
4. Fecal Analysis  NPO until gag reflex returns (2 – 4 hrs)
 Stool for Ova and Parasites  NSS gargle; throat lozenges
 Send fresh, warm stool specimen  Monitor VS
 Stool Culture  Assess : bleeding, crepitus (neck), fever, neck /
 Sterile test tube / cotton – tipped applicator throat pain, dyspnea, dysphagia, back / shoulder
 Stool for Lipids pain
 Assess steatorrhea  Advise to avoid driving for 12 hours if sedative
  fat diet, No alcohol ( 3 days ) was used.
 72 hour stool specimen ( store on ice )
 X mineral oil, neomycin SO4 2. LGI Endoscopy
Proctosigmoidoscopy (sigmoid, rectum)
5. Gastric Analysis  Clear liquid diet 24 hours before
 Measures secretion of HCI and pepsin  Administer cathartic / laxative as ordered
 NPO for 12 hours  Cleansing enema
 NGT is inserted , connected to suction  Knee – chest / lateral position
 Gastric contents collected every 15  After the procedure
minutes to 1 hour  Supine position for few minutes
 Assess for signs of perforation
RADIOGRAPHIC TESTS  Bleeding
 Pain
1. Scout Film / Flat Plate of the Abdomen  Fever
 Plain X – ray of the abdomen  Hot sitz bath for discomfort
 X belts / jewelries 3. Colonoscopy
2. UGIS ( Barium Swallow)  Sedation
 To visualize the esophagus, stomach,  Position : left side, knees flexed
duodenum and jejunum  After the procedure:
 NPO for 6 – 8 hours  Monitor VS (note for vasovagal response)
 Barium Sulfate (BaSO4) per orem  Assess for s and sx of perforation.
 X – rays taken on standing, lying position
 After the procedure: 4. Ultrasonography
 Laxative  NPO for 8 – 12 HOURS
 Increase fluid intake  Laxative as ordered ( bowel gas)
 GASTROINTESTINAL DISORDERS
ADMINISTERING GASTROSTOMY OR
JEJUNOSTOMY FEEDING Hiatal Hernia (Diaphragmatic Hernia)
 Verify doctor’s order.
 Assist client to a Fowler’s position. 1. Sliding Hiatal Hernia
 Insert feeding tube into the ostomy opening 10  Protrusion of the esophagogastric junction into
– 15 cm. (4 to 6 in.) if one is not sutured in the thoracic cavity and back into the abdominal
place. (Lubricate tube before insertion) cavity in relation to position changes
 Check the patency of the tube sutured in place – Causes:
pour 15 to 30 ml. of water into the asepto  Muscle weakness in the esophageal hiatus:
syringe.  Aging process
 Administer feeding slowly. Hold syringe 7 to 15  Congenital muscle weakness
cm. (3 to 6 inches) above the ostomy opening.  Obesity
 Flush the tube with 30 ml. of water after  Trauma
feeding.  Surgery
 Keep the client in Fowler’s position or slightly  Prolonged increases in intraabdominal pressure
elevated right lateral position for at least 30 2.Paraesophageal / Rolling Hernia
mins.  The gastric junction remains below the
 Assess status of peristomal skin. diaphragm, but the fundus of the stomach
 Make relevant documentation. and the greater curvature rolls into the
thorax next to the esophagus
Indications Cause : anatomic defect
 Major GI diseases, fistulas or inflammatory Assessment
diseases  Heartburn due to gastroesophageal reflux
 Severe trauma or burns  Dysphagia
 Severe GI side effects from radiation or  Dyspnea
chemotherapy  Abdominal pain
 Severe malnutrition  Nausea and vomiting
 Need for extensive support over an  Gastric distention, belching, flatulence
extended period. COLLABORATIVE MANAGEMENT
 Usual site of TPN catheter insertion is
subclavian vein. 1. Medications
 Place the client in Trendelenburg position  Antacids
during insertion of TPN catheter  Antiemetics
 The primary purpose of TPN is to  Histamine Receptor Antagonists
administer glucose ( 25 – 35% dextrose)  Gastric Acid Secretion Inhibitors
 Administer TPN solution at room AVOID:
temperature  Anticholinergics
 Consume prepared formulas within 24  Xanthine derivatives
hours to prevent contamination.  Ca – channel blockers
 Maintain a steady infusion rate  Diazepam
 Use infusion pump e.g. IVAC These drugs lower the LES pressure (low esophageal
 Do not attempt to “catch up” if infusion is sphincter)
delayed.
 Monitor urine and blood glucose levels. 2. Relieve pain
 Care of catheter insertion site.  Antacids
 Practice strict aseptic technique 3. Modify diet
 Cleanse site with antiseptic solution ;  High CHON diet to enhance LES pressure
change sterile dressings daily.  Small frequent feedings ( 4 to 6 )
 Monitor for signs and symptoms of  Eat slowly and chew food properly
infection Avoid :
 Provide good oral hygiene  Fatty foods
 Cola beverages
 Coffee
 Tea
 Chocolate
 Alcohol
These foods and beverages decrease LES pressure
  Assume upright position before and after eating  Pernicious anemia
(1-2 hrs.)  Villous adenoma
 X eat at least 3 hrs. before bedtime to prevent  + family history
nighttime reflex  Excess intake of raw foods
 X evening snacks  Drinking large, volume of hot tea
 Reduce BW if obese  Atrophic gastritis
 Promote lifestyle changes ASSESSMENT
 Elevate HOB 6 to 12 in. for sleep  Progressive loss of appetite
 X factors that increase intraabdominal pressure  Gastric fullness (early satiety)
 Use of constrictive clothing  Dyspepsia (4 weeks or more)
 Straining  + guaiac stool exam
 Heavy lifting  Nausea and vomiting
 Bending, stooping  Hematemesis / melena
 Coughing  Pain induced by eating, relieved by vomiting
 X smoking (causes rapid and significant drop in (late symptom)
LES pressure)  Weight loss, loss of strength, anemia,
obstruction
SURGERY  Palpable abdominal mass
Nissen Fundoplication (gastric wrap – around)
Preop Care COLLABORATIVE MANAGEMENT
 Teach on DBCT exercises, incentive Medical Management
spirometry to prevent postop respiratory  Surgery (Subtotal/ Total Gastrectomy)
complications Nursing Management
 Inform on possible postop contraptions:  Care of the client undergoing gastric surgery
Chest tube
NGT PEPTIC ULCER DISEASE
SURGERY – POSTOP CARE  Impairment of the mucosa and deeper structures
1. Facilitate AW clearance of the esophagus, stomach, duodenum or
a. Semi – Fowler’s position jejunum
b. Reinforce DBCT exercises, incentive  With remissions and exacerbations
spirometry, chest physiotherapy Cause : Unknown

2. Facilitate swallowing Theory

a. A large NGT is inserted to prevent the
fundoplication from being made too HCl + Pepsin Mucous Secretion
tightly (Protector)
b. Drainage from NG tube turns to (Aggressor)
yellowish green within first 8 hrs, ↓
postop ↑secretion:  secretion:
c. Oral fluids after peristalsis returns;   blood flow
near normal diet within 6 weeks  Irritants
d. Small, frequent meals stress
e. Maintain upright position stimulants Damage of mucous
f. Avoid gas- forming foods membrane
g. Frequent position changes and early
ambulation to clear air from the GI PEPTIC ULCER DISEASE
tract
h. Report for persistent dysphagia and PREDISPOSING FACTORS
gas pain 1.Stress
PNS ® gastric motility, HCl
GASTRIC CANCER 2. Cigarette smoking
 in middle – aged males Stimulant ; Vasoconstrictor
3. Alcohol
Predisposing Factors Irritant; vasoconstrictor; beer gastric acid
 Excess intake of nitrite – cured, salt – cured and secretion
smoke – cured foods 4. Caffeine
 Cigarette smoking Stimulant ; vasoconstrictor
 Chronic achlorhydria 5. Drugs
 ASA, NSAIDs Steroids  executive ulcer
6. Gastritis
HCl; mucous ulceration
7. Infection
Campylobacter/ H. Pylori  80% incidence
8. Zollinger – Ellison Syndrome
Pancreatic tumor  25 – 50 years
(gastrinoma)
 well – nourished

↑Gastrin secretion  oversecretion of HCI

↓HCL secretion  radiates to right

 3 to 4 hrs. p.c.
Multiple areas of ulcerations
9. Irregular, hurried meals (stressful)  relieved by food
10. Fatty, spicy, highly acidic foods,  commonly experienced 12MN to 3Am
(stimulants, irritants)
11. Type A personality  melena, more common
 “stress personality”
12. Type O blood
 complications
 pepsinogen levels ® PEPSIN
 obstruction
13. Genetics
 hemorrhage
 in parietal cell mass ® acid secretion  perforation
 peritonitis
GASTRIC ULCER
HEMORRHAGE : most life threatening
 “poor man’s” ulcer complication of PUD ® hypovolemic shock
 “laborer’s ulcer

COLLABORATIVE MANAGEMENT
 20 % incidence Medications
1. Antacids
 50 years and above  Neutralize HCl
 Taken 1 to 2 hrs. p.c.
 Malnourished  Amphogel (AL – OH)
 Basaljel (AL – Carbonate)
 Normal HCl secretion
 Maalox (AL – Mg – OH)
 normal gastric emptying rate
 Gaviscon (AL – Mg – Trisilicate)
 back – diffusion of HCl
 Milk of Magnesia (Mg – OH)
 radiates to left
 Riopan (Magaldrate)
 ½ to 2 hrs. p.c.
 X relieved by food
 Alka – 2 (Calcium carbonate)
 Tums (Calcium carbonate)
 Rolaids (Calcium carbonate)
 nausea and vomiting, hematemesis  Mylanta (AL – Mg – OH with Simethicone)
common  Maalox plus Gelusil (AL – Mg – OH with
 complications Simethicone)
 hemorrhage  Magnesium based ® diarrhea
 perforation  Aluminum – based ® constipation
 peritonitis 2. Histamine (H2) receptor antagonists
 Reduces HCl secretion
 Taken with meals
 Tagamet (Cimetidine)
 Zantac (Ranitidine)
 DUODENAL ULCER
 Pepcid (Famotidine)
 Axid (Nizatidine)
Side effects: 5. Fatty foods
 Diarrhea 6. Coffee, tea, cola drinks, chocolate
 Abdominal cramps 7. Spices, red /black pepper
 Confusion 8. Alcohol
 Dizziness 9. Bedtime snacks
 Weakness 10. Binge eating
 Cimetidine – antiandrogenic (gynecomastia,  11. Large quantities of milk (400 mls/day
libido, impotence) is allowed)
3.Cytoprotective  Quit smoking
 Coats ulcer  Coping
 prostaglandin synthesis  Stress Therapy
 Taken on an empty stomach (30 – 60 mins.  Recreation and hobbies
before meals)  Regular pattern of exercise
 Carafate (Sucralfate)  Stress reduction at home and at work
4. Prostaglandin analogue
 Replaces gastric prostaglandin NURSING MANAGEMENT OF THE PATIENT WITH
 Cytotec (Misoprostol) GASTRIC SURGERY
5. Proton pump inhibitor  Preop Care
 Gastric acid secretion inhibitor o Provide psychosocial support
 Losec (Omeprazole) o Teach DBCT exercises (high
6. H. Pylori Drug treatment abdominal incision ® respiratory
 Pepto – Bismul (bismuth compound) complications)
 Amoxicillin / Tetracycline o Provide nutritional support – TPN
 Flagyl (Metronidazole) o Inform about postop measures
SURGERY  Nasogastric tube
1.Vagotomy  TPN until peristalsis returns
 Resection of the vagus nerve
 Decrease cholinergic stimulation POSTOP CARE
 1.Promote patent airway and ventilation
 HCl secretion  Semi – Fowler’s position
gastric motility  Reinforce DBCT exercises , incentive
spirometry
2.Pyloroplasty  Administer analgesic before activities
 Surgical dilatation of the pyloric sphincter  Splint incision before patient coughs
 Improves gastric emptying of acidic chyme  Encourage early ambulation

3.Antrectomies 2.Promote adequate nutrition

 Removal of 50% of the lower part of the
stomach
Types
 Billroth I (Gastroduodenostomy)
 Billroth II (Gastrojejunostomy)
 The duodenum is bypassed to permit the flow
of the bile
4.Subtotal Gastrectomy
 Removal of 75% of the distal stomach with
Billroth I or II repair
NURSING MANAGEMENT
 Relieve pain
 Take prescribed medications as ordered
 Promote a healthy lifestyle
 Diet
1. Liberal bland diet during exacerbation
2. Eat slowly and chew food properly
3. Small, frequent feedings during
exacerbation
4. Avoid the following:
 NPO until peristalsis returns
 Measure NG drainage accurately (reddish for
the first 12 hrs)
 Monitor for signs of leakage of anastomosis,
e.g. dyspnea, pain, fever, when oral fluids are
initiated
 Small, frequent feedings
 Monitor for early satiety and regurgitation
 Eat less food at a slower pace
 Monitor weight regularly
3.Prevent potential complications
a.Bleeding – first 24 hours; 4th to 7th day postop due to
nonhealing
b.Monitor NG drainage for blood
 Avoid unnecessary irrigation or repositioning of
the NGT
 Monitor for signs of peritonitis:
 Severe abdominal pain, rigidity fever
c.Dumping Syndrome
 A group of unpleasant vasomotor and G.I. 
symptoms caused by rapid emptying of gastric content Abscess
into the jejunum 
 Early signs and symptoms (5 to 30 minutes p.c.) Gangrene
 Weakness 
 Tachycardia Perforation (24 to 36 hours)
 Dizziness 
 Diaphoresis Peritonitis
 Pallor ASSESSMENT
 Feeling of fullness or discomfort  Acute abdominal pain that usually starts in the
 Nausea epigastric or umbilical region.
 diarrhea  Pain gradually becomes localized in RLQ / Mc
 Late signs and symptoms (2 to 3 hrs. p.c.) Burney’s point (halfway between the umbilicus
Hyperglycemia and the anterior spine of the ilium)
  Pain is initially intermittent then becomes
insulin secretion steady and serves over a short period.
  Anorexia, nausea and vomiting
HYPOGLYCEMIA  Rigid abdomen, guarding
 Rebound tenderness (Blumberg sign)
MANAGEMENT OF DUMPING SYNDROME  Fever (temperature = 38 – 38.5ºC)
 Eat in a recumbent or semi – recumbent  Elevated wbc (above 10,000 / cu. mm.)
position  Psoas sign (lateral position with right hip
 Lie down after meal (left side) flexion)
 Small, frequent feedings  Decreased or absent bowel sounds
 Moderate fat, high protein diet COLLABORATIVE MANAGEMENT
 Limit carbohydrates, no simple sugars  Bed rest
 Give fluids after meals  NPO
 Avoid very hot and cold foods and beverages  Relieve pain (cold application over the
 Anticholinergic or antispasmodic abdomen)
 Avoid factors that increase peristalsis, thereby
d.Marginal Ulcers rupture:
 Occur where gastric acids contact the operative  Heat application over the abdomen
site (site of anastomosis or jejunum)  Laxative
e.Alkaline Reflux Gastritis  Enema
 Caused by reflux of duodenal contents  IVF therapy to maintain fluid – electrolyte
f.Vitamin B12 Deficiency balance
 Due to partial or total loss of the intrinsic factor  Antibiotic therapy
secreted by the parietal cells of the stomach  Surgery : Appendectomy

APPENDICITIS APPENDECTOMY
 Inflammation of the vermiform appendix  Spinal anesthesia
 More common in males, 10 to 30 years of age  Flat on bed for 6 – 8 hours
 Causes  Monitor for return of sensation in the lower
o Obstruction by fecalith or foreign bodies, extremities
infection  NPO until peristalsis returns
o Low fiber diet  Ambulation after 24 hours
o High intake of refined carbohydrates  If appendicitis ruptured (peritonitis): with
PATHOPHYSIOLOGY penrose drains; Semi – Fowler’s position to
Inflammation localize inflammation within the pelvic area
  Resume all normal
 Intraluminal Pressure  activities within
  2 to 4 weeks
PERITONITIS
• Lymphoid Swelling
 Inflammation of the peritoneum
• Decreased Venous Drainage
• Thrombosis
• Bacterial Invasion  Causes
 Ruptured appendix
 Perforated peptic ulcer ↓
 Diverticulitis Inflammation and infection
 Pelvic inflammatory disease ↓ ↓
 Urinary tract infection or trauma Scarring
 Bowel obstruction Abscess
 Bacterial invasion • Bleeding
• Perforation
ASSESSMENT • Peritonitis
 Abdominal pain and tenderness
 Abdominal guarding and rigidity ASSESSMENT
 Abdominal distention  Crampy lower left quadrant abdominal pain worsens
 Paralytic ileus with movement, coughing or straining
 Fever  Low - grade fever
 Elevated wbc (20,000/cu. mm. or higher)  Chronic constipation with episodes of diarrhea
 Nausea and vomiting  Nausea and vomiting
 Signs of early shock:  Abdominal distention and tenderness
 Tachycardia  Occult bleeding
 Tachypnea  Signs and symptoms of peritonitis due to
 Oliguria development of abscess or perforation
 Restlessness COLLABORATIVE MANAGEMENT
 Weakness  High fiber diet
 Pallor  Liberal fluid intake of 2,500 to 3,000
 Diaphoresis mls./day
 Avoid nuts and seeds which can become
COLLABORATIVE MANAGEMENT trapped in the diverticula
 Monitor VS, I and O  Bulk – forming laxatives
 NGT is inserted to relieve abdominal distention  During an acute episode:
 Bed rest in Semi – Fowler’s position  Bed rest
 Encourage deep breathing exercises  NPO, then clear liquids to rest the bowel
 Peritoneal lavage with warm saline  X other foods to prevent further irritation
 Insertion of drainage tubes of the mucosa
 Fluid, electrolyte and colloid replacement  IVF’s, antibiotics, analgesics,
 Antibiotics anticholinergics (Pro – Banthine)
 TPN solutions  NGT insertion to relieve distention
 Weight loss to reduce intraabdominal
DIVERTICULITIS pressure
 Diverticulum is outpouching of the mucosal CHRONIC INFLAMMATORY BOWEL
lining of the G.I. Tract, commonly in the colon DISORDERS (CIBD’s)
 Diverticula / diverticulosis are multiple A. Regional Enteritis (Crohn’s Disease)
outpouchings  Transmural
 Diverticulitis is acute inflammation and  Ileum / Ascending colon
infection caused by trapped fecal material and  Cause
bacteria  Unknown
Cause  Jewish
 low fiber diet  Environmental
 Age 20 – 30 40 – 60
PATHOPHYSIOLOGY  Bleeding ↓
Low fecal volume in the colon  Perianal Involvment ↑
↓  Fistulas ↑
Increased intraluminal pressure  Rectal Involvement 20%
↓  Diarrhea 5 – 6 soft stool / day
Decreased muscle strength in  Abdominal Pain Ö
the colon wall  Weight Loss Ö
↓  Interventions-Diet, TPN, Steroids, Azulfidine,
Herniation / Outpouching Ileostomy / Colectomy
of mucuous membrane
Entrapment of fecal material B. Ulcerative Colitis
and bacteria  Mucuous Ulceration
  Rectum / Lower colon  Characterized by compromised blood flow to
 Cause the trapped segment of bowel. Intestinal obstruction
Unknown occurs, and gangrene of the viscera can develop rapidly
Familial
o Jewish ASSESSMENT
Emotional stress  Lump: groin, around umbilicus, from an old
 Age 15 – 40 surgical incision
 Bleeding  Disappears when lying down, reappears with
 Severe standing , coughing, straining or lifting.
 Perianal Involvment -Mild  Sensation of heaviness
 Fistulas - Rare  Vague discomfort
 Rectal Involvement - 100%  Nausea, vomiting, distention, pain (strangulated
 Diarrhea - 20 – 30 watery stool / day hernia)
 Abdominal Pain - Ö COLLABORATIVE MANAGEMENT
 Weight Loss - Ö Surgery : Herniorrhaphy / Hernioplasty
 Interventions - Diet
TPN Preop Care
Steroids  Assess for presence of URTI. Sneezing or
Azulfidine coughing could weaken the repair.
Ileostomy / Postop Care
Proctocolectomy  Encourage to deep breathe, but no coughing
exercises
ABDOMINAL HERNIAS  Increase fluid intake to prevent constipation.
 A protrusion of an organ or structure through a  Monitor for bladder distention.
weakened abdominal muscle; a congenital or  Ice bags are applied after inguinal hernia repair
acquired defect. to minimize discomfort during ambulation
 Causes Discharge Teachings:
 Congenital / acquired muscle weakness  X heavy lifting, pushing, pulling for about 6
 Increased intraabdominal pressure weeks
 Heavy lifting  X driving, climbing stairs for few weeks.
 Obesity  Monitor incision for signs of infection.
 Pregnancy  Stool softeners or bulk laxatives as prescribed
to prevent straining at defecation.
TYPES OF HERNIA  Sexual activity may be resumed once healing is
1. Reducible – can be returned by manipulation complete and comfort assured.
2. Irreducible – requires surgery
3. Inguinal Hernia – common among males COLORECTAL CANCER
Indirect Inguinal Hernia  Cause: Unknown
 Protrusion of bowel is through inguinal ring,  Predisposing Factors:
follows the course of spermatic cord and moves down  Age above 40 years
into the scrotum  Predisposing Factors
Direct Inguinal Hernia  Ö low in fiber
 Protrusion is through inguinal wall at the point  Ö high in fat, protein and refined carbohydrates
of muscle weakness  Obesity
Umbilical Hernia – common among infants  History of chronic constipation
 Protrusion is through congenital defect in  History of IBD, familial polyposis or colon
muscle polyps
Femoral Hernia – common among females  Family history of colon cancer
 Protrusion is through femoral ring and down  Most Common Site: Rectosigmoid area (70%)
the femoral canal ASSESSMENT
Incisional Hernia – common after surgery Ascending (Right) Colon Cancer
 Protrusion is through inadequately healed  Occult blood in stool
surgical repair  Anemia
Incarcerated Hernia  Anorexia and weight loss
 Characterized by bowel obstruction  Abdominal pain above umbilicus
Strangulated Hernia  Palpable mass
Distal Colon / Rectal Cancer
 Rectal bleeding
 Changed bowel habits
 Constipation or Diarrhea
 Pencil or ribbon – shaped stool
 Tenesmus
 Sensation of incomplete bowel emptying
Duke’s Classification of Colorectal Cancer
 Stage A: confined to bowel mucosa, 80 – 90%
5- year survival rate
 Stage B: invading muscle wall
 Stage C: lymph node involvement
 Stage D: metastases or locally unresectable
tumor, less than 5% 5 – year survival rate
Guidelines for Early Detection of Colorectal Cancer
 Digital rectal examination yearly after age 40
 Occult blood test yearly after age 50
 Proctosigmoidoscopy every 5 years after age
50, following 2 negative results of yearly
examination
COLLABORATIVE MANAGEMENT
Surgery
A. Hemicolectomy for ascending and transverse colon
cancer
B. Abdomino – Perineal Resection (APR) for
rectosigmoid cancer
 There are 2 incisions: lower abdomen incision
to remove to sigmoid; perineal incision to
remove the rectum
 T – binder is used to secure perineal dressing
 Necessitates permanent colostomy
Chemotherapy
 Fluorouracil is the most effective drug for
colorectal cancer
Radiotherapy
 Adjuvant treatment for rectal cancer
COLONIC SURGERY
Preop Care
 Provide psychosocial support
 Thorough bowel cleansing:
 Diet modification
 Low residue diet 3 to 5 days preop, to reduce
the bulk of stool in the colon
 Clear liquid diet 24 hours preop
 Mechanical cleansing
 Laxatives as ordered
 Cleansing enema as ordered
 Pharmacologic suppression of colon bacteria
 Neomycin sulfate tablets to reduce bacterial
flora. (it is poorly absorbed in the colon,
thereby enhance excretion of colonic bacteria)
 Vitamin C and K supplement because these are
lost during repeated enema administration
TYPES OF COLOSTOMIES
Ascending Colostomy
 Stoma is on the right abdomen
 Fecal drainage is watery
Transverse (Double – Barreled) Colostomy
 The right stoma is called proximal stoma; drains
semi – formed feces
 The left stoma is called distal stoma; drains mucus
Transverse Loop Colostomy
 Has 2 openings in the transverse colon, but one
stoma
 Indicated in IBD’s
Descending and Sigmoid Colostomy
 Stoma on the left abdomen
 Fecal drainage is well - formed
COLONIC SURGERY
Postop Care
 Managing the perineal wound (APR)
 May require up to 6 months to completely heal
 Wound irrigations with normal saline and
absorbent dressings until wound closes.
 Drainage is initially copius and serosanguinous,
to be drained at regular basis to prevent
infection and abscess formation.
 T – binder is used to secure perineal dressing.
 Sitz baths once more the patient is ambulatory
 Foam pads or soft pillows to promote comfort
when sitting.
 Side – lying position during sleep.
 Stoma Monitoring
 The stoma is red and with slight edema for 5 –
7 days
 Dark, dusky, or brown – black stoma indicates
ischemia and necrosis
 The stoma should protrude by ½ to ¾ inches
over abdomen
 Flatus and fecal drainage usually begin in 4 to 7
days, as peristalsis returns
 Empty the pouch when it is 1/3 to ½ full of
stool
 Loop colostomy is opened 48 – 72 hours
postop, with cautery at bedside
 Teaching for Self – Care
Stoma Care
 Gently encourage the client to look at the stoma
 Inform that stoma has no touch or pain
sensation
 Instruct to report immediately any purple or
black discoloration of the stoma
 Cleanse the stoma initially with antiseptic
 Skin care
 Wash the skin with warm water, pat dry
 Assess skin for signs of irritation or infection.
 When pouch seal leaks, change pouch
immediately
 Use skin barrier to protect the peristomal skin
from liquid stool
  E.g. karaya preparation  Use smaller – sized pouch or pouch cover during
 Skin infection caused by Candida Albicans is sexual activity
treated with nystatin (Mycostatin) powder  Use of a binder or special underwear to hold the
COLOSTOMY IRRIGATION pouch secure
 Initial colostomy irrigation is done to stimulate
peristalsis; subsequent irrigations are done to HEMORRHOIDS
promote evacuation of feces at a regular and  Dilated blood vessels beneath the lining of the
convenient time skin in the anal canal
 Recommended with sigmoid colostomy Two Types of Hemorrhoids
 Initiated 5 to 7 days postop  External hemorrhoids – occur below the anal
 Done in semi – Fowler’s position; then sitting on a sphincter
toilet bowl once ambulatory.  Internal hemorrhoids – occur above the anal
 Use warm normal saline solution sphincter
 Initially, introduce 200 mls. of NSS then 500 to Causes
1,000 mls. Subsequently  Chronic constipation
 Dilate stoma with lubricated gloved finger before  Pregnancy
insertion of catheter  Obesity
 Lubricate catheter before insertion.  Prolonged sitting or standing
 Insert 2 to 4 inches of the catheter into the stoma  Wearing constricting clothings
 Height of solution 18 inches above the stoma  Disease conditions like liver cirrhosis, RSCHF
 If abdominal cramps occur during introduction of ASSESSMENT
solution, temporarily stop the flow of solution until  Constipation( in an effort to prevent pain or
peristalsis relaxes. bleeding associated with defecation.)
 Allow the catheter to remain in place for 5 to 10  Anal pain
minutes for better cleansing effect; then remove  Rectal bleeding
catheter to drain for 15 to 20 minutes.  Anal itchiness
 Clean the stoma, apply new pouch  Mucous secretion from the anus
MANAGING ODOR  Sensation of incomplete evacuation of the
 Avoid gas – forming and foul odor foods, e.g. rectum
dairy products , highly seasoned foods, fish,  Internal hemorrhoids may prolapse
cabbage, celery, cauliflower, eggs, carbonated COLLABORATIVE MANAGEMENT
beverages, nuts  High fiber diet, liberal fluid intake
 Rinse pouch with tepid water or weak vinegar  Bulk laxatives
solution.  Hot Sitz bath, warm compress
 Place deodorant tablet or small amount of  Local anesthetic application – Nupercaine
mouthwash or a piece of charcoal into the  Surgery
pouch. o Hemorrhoidectomy
 X use pulverized ASA – it causes irritation of o Sclerotherapy (5% phenol in oil)
the stoma and damages the colostomy appliance o Cryosurgery
Postop Care o Rubber – band ligation
 Supporting a Positive Self – Concept Preop Care
 Encourage to view the stoma  Low residue diet to reduce the bulk of stool
 Encourage to verbalize feelings, fears and  Stool softeners
concern about stoma POSTOP CARE
 Encourage to participate in colostomy care  Promotion of comfort
 Encourage to gradually resume all usual  Analgesics as prescribed
activities  Side – lying position
 Avoid tight belts or waistbands over the stoma  Hot Sitz bath 12 to 24 hrs. postop
 Advise to always carry colostomy supplies  Promotion of elimination
when travelling  Stool softener as prescribed
 Resolving Grief  Encourage the client to defecate as
 Encourage client to express feelings of loss soon as the urge occurs
 Explore client’s usual coping strategies for handling  Analgesic before initial defecation
grief  Enema as prescribed, using a small –
 Preventing Sexual Dysfunction bore rectal tube
 Explore positions that minimize stress and pressure  Patient Teaching
on the pouch  Clean rectal area thoroughly after each
 Empty and clean the pouch before sexual activity defecation
  Sitz bath at home especially after defecation
 Avoid constipation:
 High – fiber diet
 High fluid intake
 Regular exercise
 Regular time for defecation
 Use stool softener until healing is complete
Notify physician for the following:
 Rectal bleeding
 Suppurative drainage
 Continued pain on defecation
 Continued constipation