Ihterventions for Clients with Noninflammatory Intestinal Disorders

Interventions for Clients with Intestinal Disorders

 

The most common presenting symptoms associated with noninflammatory intestinal disorders include alterations in bowel patterns, abdominal pain, and rectal bleeding (Figure 57-1). Symptoms of this type require investigation, since they can be associated with serious illnesses, such as intestinal ob­struction or colorectal cancer.

IRRITABLE BOWEL SYNDROME

OVERVIEW

Irritable bowel syndrome (IBS) is the most common diges­tive disorder seen in clinical practice. IBS is a functional gas­trointestinal (GI) disorder, characterized by the presence of chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating (Alderman, 1999). IBS is estimated to oc­cur in 10% to 22% of the population of the United States. It is believed to be due to impairment in the motor or sensory function of the GI tract. Motility changes result in changes in the normal bowel elimination pattern to a pattern of diarrhea, constipation, or alternating diarrhea and constipation. Symptoms of IBS typically begin to appear in young adulthood. The exact cause is unknown, since no structural or infectious etiology has been identified. Physical factors, such as diver-ticular disease, ingestion of coffee or other gastric stimulants, or lactose intolerance may contribute to IBS. IBS follows a pattern of intermittent remissions and exacerbations.

The diagnosis of IBS is made by careful history taking, documenting the presence of characteristic symptoms; labo­ratory tests; and any other diagnostic tests to exclude a more serious condition. There are no specific biomarkers for IBS, but characteristic symptoms known collectively as the Man­ning criteria are typically present in clients with IBS. The Manning criteria include abdominal pain relieved by defeca­tion or associated with changes in stool frequency or consis­tency, abdominal distention, the sensation of incomplete evac­uation of stool, and the presence of mucus with stool passage. Bowel function changes progressively and eventually forms the characteristic pattern.

Recent studies have demonstrated that clients with IBS ex­perience alteration in rectal visceral sensation. Balloon dis­tention in the rectum or sigmoid colon resulted in abdominal pain at levels higher in clients with IBS than in those without IBS (Schmulson et al., 2000).

The course of the illness is generally specific to the client, and most clients can identify factors that precipitate exacer­bations, such as diet, stress, or anxiety. There are no changes in the bowel mucosa and therefore no serious health conse­quences. However, the irregular bowel patterns and associated cramps often wreak havoc on the person’s lifestyle. Psy-chosocial factors have been thought to play a significant role in IBS. However, the evidence is often contradictory (Carlson, 1998). Food intolerance may be associated with IBS. Dairy products and grains can contribute to bloating, flatulence, and distention. In one study, individuals who reported intoler­ances to multiple foods were more likely to report IBS (Locke et al., 2000). Finally, IBS symptoms have also been associated with analgesic use (see the Evidence-Based Practice for Nurs­ing box at right).

 WOMEN’S HEALTH CONSIDERATIONS The prevalence of IBS in women is 2:1 as compared with men. Furthermore, several studies indicate that there may be a link between a history of physical, sexual, or emotional abuse and the subsequent development of IBS in women (Toner & Akman, 2000).

 COLLABORATIVE MANAGEMENT

Assessment

The client is asked about a history of abdominal pain, changes in the bowel pattern or consistency of stools, and the passage of mucus. The nurse collects information on all medications the client is taking, since many medications cause GI symp­toms similar to those of IBS. A careful dietary history, in­cluding the use of caffeinated beverages or beverages sweet ened with sorbitol or fructose, which can cause bloating or di­arrhea, should be elicited.

EVIDENCE-BASED PRACTICE

Critique. Although this study provides early insight into possible risk factors not before associated with IBS, the re­sults must be interpreted with caution. Although the sample size is adequate, the self-selection and cross-sectional de­sign, and limited geographic area lend bias and an inability to generalize the results to the study. Moreover, the self-report methodology and the fact that the subjects were not neces­sarily medically evaluated for their symptoms limits the inter­pretation of the findings.

Implications for Nursing. Although the study results cannot be generalized to the population, nurses collecting history in­formation can include questions concerning analgesic use and food allergies in individuals suspected of having IBS. Individu­als who identify themselves as having food sensitivities may also have symptoms of IBS that require investigation. Although analgesics in themselves may not be causative, it is possible that clients with IBS present with other forms of pain induced by the disorder. Careful questioning during the intake history can provide more information into the pathogenesis of IBS.

A flare-up consisting of worsening cramps, abdominal pain, and diarrhea or constipation usually brings the client to the health care provider. The most common symptom of IBS is pain in the left lower quadrant of the abdomen. The client reports increased pain after eating and relief after a bowel movement. Nausea may be associated with mealtime and defecation. The crampy abdominal patterns are accompanied by constipation or diarrhea. 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. Clients with IBS often complain of belching, gas, anorexia, and bloating.

The client generally appears well, with a stable weight, and nutritional and fluid levels are withiormal ranges. The nurse inspects and auscultates the abdomen. Bowel sounds are generally within normal range and may be somewhat quiet with constipation. On percussion of the abdomen, tympanic sounds may be heard over loops of filled bowel. On palpation, there may be diffuse (widespread) tenderness, which is gen­erally worse if the sigmoid colon is palpable. The rectal ex­amination may reveal hard or soft stool.

Routine laboratory work (including a complete blood count [CBC], serologic tests, serum albumin, erythrocyte sed­imentation rate, and stools for occult blood) is normal in IBS. The health care provider typically orders a barium enema ex­amination for clients suspected of having IBS. Colonic spasm is ofteoted during the procedure; however, this finding is not diagnostic. In the absence of other diagnostic findings, colonic spasm supports the diagnosis (Figure 57-2).

The evaluation of IBS is not complete without flexible sig-moidoscopy in adults younger than 40 years of age or colonos-copy in adults older than 40 years of age. A colonoscopy often demonstrates intense spastic contractions, which often stimulate painful sensations. Otherwise, the bowel mucosa appears con­tinuous, smooth, and pink.

 Interventions

The client with IBS is most often cared for on an ambulatory basis. Interventions are directed at education, dietary modifi­cation, drug therapy, and stress management.

CLIENT EDUCATION. The nurse educates the client re­garding the chronic nature of the disorder. Education is also directed at identifying food intolerances and needed dietary modifications. Information regarding what constitutes normal bowel function and laxative abuse is provided. The client must be alert to the urge to defecate and evacuate promptly to avoid straining and should plan to allow time and privacy in the bathroom.

DIET THERAPY. The initial treatment of IBS focuses on dietary modifications. The nurse assists the client in identify­ing and eliminating offending or upsetting foods. He or she is advised to limit caffeine and to avoid alcohol, beverages that contain sorbitol or fructose, and other gastric irritants. Milk and milk products are to be avoided if lactose intolerance is suspected.

Fiber supplements are usually recommended whatever the predominant symptom may be. Dietary fiber and bulk help produce bulky, soft stools and establish regular bowel habits. The client should ingest approximately 30 to 40 g of fiber each day. Eating regular meals, drinking 8 to 10 cups of liquid each day, and chewing food slowly promote normal bowel function. The nurse may need to collaborate with the dietitian to help the client and family or significant others with meal planning.

DRUG THERAPY. Drug therapy is directed at the major symptom. The health care provider may prescribe bulk-form­ing laxatives, antidiarrheal agents, 5HT₃ antagonists, anti-cholinergic agents, or tricyclic antidepressants.

For the treatment of constipation-predominant IBS, bulk-forming laxatives, such as psyllium hydrophilic mucilloid (Metamucil) or calcium polycarbophil (Mitrolan), are gener­ally taken at mealtimes with a glass of water. The hydrophilic properties of these medications help prevent dry, hard, or liq­uid stools.

Diarrhea-predominant IBS is typically treated with antidiar­rheal agents, such as diphenoxylate hydrochloride with atropine sulfate (Lomotil) or loperamide (Imodium) (Chart 57-1).

For IBS where pain is the predominant symptom, anti-cholinergics or antispasmodics, such as dicyclomine hydro-chloride (Bentyl) and propantheline bromide (Pro-Banthine), help relieve abdominal cramping and intestinal spasm. Tri­cyclic antidepressants have also been successfully used in this form of IBS. It is unclear whether their effectiveness is due to the antidepressant or anticholinergic effects of the drugs. If clients experience postprandial discomfort (discomfort after eating), they should take these medications 30 to 45 minutes before mealtime.

STRESS MANAGEMENT. Stress management is based on the client’s current and ongoing stressors and available re­sources. After the nurse completes a detailed psychosocial as­sessment, the nurse and the client set expected outcomes and plan appropriate interventions. Relaxation techniques can help the client learn skills for managing the illness. Understanding the illness empowers the client to take certain actions (e.g., diet modification and exercise) that can significantly af­fect the course of the illness.

If the client is in a stressful work or family situation, per­sonal counseling may be helpful. The nurse may need to make appropriate referrals or assist in making appointments. The opportunity to discuss problems and attempt creative problem solving is often helpful. The nurse teaches the client that reg­ular exercise is important for managing stress and promoting regular bowel elimination.

HERNIATION         

 OVERVIEW

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.

    Defects in the muscle wall result from weakened collagen or widened spaces at the inguinal ligament. These muscle weaknesses can be inherited or acquired as part of the aging process. Increases in intra-abdominal pressure as a result of pregnancy, obesity, abdominal distention, ascites, heavy lift­ing, or coughing can contribute to their occurrence.

The most common types of abdominal hernias (Figure 57-3) are indirect, direct, femoral, umbilical, and inci-sional. An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine or omen-turn. 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 obese individuals.

Incisional, or ventral, hernias occur at the site of a previ­ous surgical incision. These hernias result from inadequate healing of the incision, which is most often caused by post­operative wound infections, inadequate nutrition, and obesity.

Hernias may also be classified as reducible, irreducible (incarcerated), or strangulated. A hernia is reducible when the contents of the hernial sac can be placed back into the ab­dominal cavity by gentle pressure. An irreducible (incarcerated) hernia cannot be reduced or placed back into the ab­dominal cavity. Any hernia that is not reducible requires immediate surgical evaluation.

A hernia is strangulated when the blood supply to the her–niated segment of the bowel is cut off by pressure from the hernial ring (the band of muscle around the hernia). If a her­nia is strangulated, there is ischemia and obstruction of the bowel loop. This can lead to necrosis of the bowel and possi­bly bowel perforation. Signs of strangulation are abdominal distention, nausea, vomiting, pain, fever, and tachycardia.

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 of heavy objects.

Indirect inguinal hernias, the most common type, are most frequent in men because they follow the tract that develops when the testes descend into the scrotum before birth. Direct hernias occur more often in older adults. Femoral and adult umbilical hernias are most common in obese or pregnant women. Incisional hernias can occur in people who have un­dergone abdominal surgery.

CONSIDERATIONS FOR OLDER ADULTS

BBSThe older adult with a strangulated hernia may not com­plain of pain but instead may present with nausea and vomit­ing. The nurse must carefully evaluate the client complaining of any of these symptoms, since they may require immediate medical and eventually surgical intervention.

COLLABORATIVE MANAGEMENT

 Assessment

The client with a hernia typically comes to the health care provider’s office or the emergency department with a com­plaint of a “lump” or protrusion felt at the involved site. The development of the hernia may be associated with straining or lifting.

To perform an abdominal assessment, the nurse inspects the abdomen when the client is lying and again when he or she is standing. If the hernia is reducible, it may disappear when the client is lying flat. The examiner asks the client to strain or per­form the Valsalva maneuver and observes for bulging. The ab­domen is auscultated for active bowel sounds. Absent bowel sounds may indicate obstruction and strangulation.

To palpate the hernia, the health care provider gently ex­amines the ring and its contents by inserting a finger in the ring and noting any changes when the client coughs. The nurse never forces the hernia to reduce; that maneuver could cause strangulated intestine to rupture.

If a male client suspects a hernia in his groin, the health care provider has him stand for the examination. Using the right hand for the client’s right side and the left hand for the client’s left side, the health care provider invaginates the loose scrotal skin with the index finger, following the spermatic cord upward to the external inguinal cord. At this point, the client is asked to cough, and the health care provider notes any palpable herniation.

 Interventions

The type of treatment selected will depend on client factors, as well as the type of hernia.

NONSURGICAL MANAGEMENT. If the client is not a surgical candidate and the hernia is incarcerated, no attempt should be made to reduce the hernia. Instead, the health care provider may prescribe a truss. A truss is a pad made with firm material; it is held in place over the hernia with a belt to help keep the abdominal contents from protruding into the hernial sac. If a truss is used, it is applied only after the physi­cian has reduced the hernia. The client usually applies the truss before arising. The nurse teaches the client to assess the skin under the truss daily and to protect it with a light layer of powder.

SURGICAL MANAGEMENT. Surgical repair of a hernia is the treatment of choice. Surgery is often performed on an am­bulatory care basis for adult clients who have no pre-existing health conditions that would complicate the operative course. In same-day surgery centers, anesthesia may be local, regional, or general, and the surgery may be laparoscopic. More exten­sive surgery, such as a bowel resection or temporary co-lostomy, may be necessary if strangulation results in a gan­grenous section of bowel. Clients undergoing extensive surgery are hospitalized for a longer period of time.

Herniorrhaphy is the surgery of choice for hernia repair. Hernioplasty is performed less often but can be performed in conjunction with a herniorrhaphy.

PREOPERATIVE CARE. The nurse prepares the client for surgery (see Chapter 17). He or she may be instructed to have one or two enemas the night before or the morning of surgery, depending on the surgeon’s preference. If outpatient surgery is planned, the nurse assists the client in making appropriate arrangements for travel to home and for home care.

OPERATIVE PROCEDURES. During a herniorrhaphy, the surgeon makes an abdominal incision and places the con­tents of the hernial sac back into the abdominal cavity before closing the opening. When a hernioplasty is performed, the sur­geon reinforces the weakened muscle wall with mesh, fascia, or wire. The surgeon may opt to perform the surgery through a lap-aroscope instead of using the open surgical method.

POSTOPERATIVE CARE. Postoperative care of the client is the same as that described in Chapter 19, except that clients who have undergone surgery for hernias are told to avoid coughing. To promote lung expansion, the nurse encourages deep breathing and frequent turning. With repair of an indirect inguinal hernia, the physician often orders a scrotal support and ice bags to be 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. The nurse en­courages early ambulation on the day of surgery if it is not contraindicated by scrotal swelling or pre-existing conditions. Ambulation helps promote comfort and a feeling of well-being and decreases the risk of postoperative complications.

In the immediate postoperative period, the client may ex­perience difficulty voiding. The nurse allows the male client to stand to allow a more natural position for gravity to facili­tate voiding and bladder emptying. Techniques to stimulate voiding, such as allowing water to run, may also be used. Careful monitoring of intake and output alerts the nurse to voiding problems early. The nurse carefully palpates the ab­domen for distention. A fluid intake of at least 1500 to 2500 mL/day prevents dehydration and maintains urinary function. Most surgeons order catheterization every 6 to 8 hours if the client cannot void. The interval between catheterizations should not be prolonged; a distended bladder can stress the in­cision and increase discomfort.

Most clients have uneventful recoveries after hernia re­pairs. Surgeons generally allow clients to return to their usual activities after surgery, with avoidance of straining and lifting for 2 weeks. Depending on the site and the extent of repair, as well as the client’s general physical condition, this period may be extended to 6 weeks.

The nurse provides 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.

The client is also instructed to keep the wound dry and clean and to replace the sterile dressing daily if indicated. Showering is permitted if allowed by the surgeon.

COLORECTAL

OVERVIEW

Cancer of the colon and rectum is the third most common can­cer in the United States and occurs equally in men and women. Cancer of the colon ranks third in estimates for cancer deaths in the United States (Greenlee et al., 2000). Colorectal cancer can occur at any age but is most prevalent in individuals over the age of 50. Although the death rate from large-bowel cancer may be decreasing slightly, this disease is lethal in a significant number of cases because it is ofteot detected until an ad­vanced stage, when metastasis has occurred.

Pathophysiology

Ninety-five percent of colorectal cancers are adenocarcino-mas. Adenocarcinomas are tumors that arise from the glandu­lar epithelial tissue of the colon. Colorectal cancer develops as a multistep process, resulting in a number of molecular changes, such as loss of key tumor suppressor genes and acti­vation of certain oncogenes that alter colonic mucosa cell di­vision. The increased proliferation of the colonic mucosa forms polyps that can be transformed into malignant tumors. The majority of colorectal cancers are believed to arise from adenomatous polyps that present as a visible protrusion from the mucosal surface of the bowel.

Tumors occur in different areas of the colon, with 70% oc­curring on the right side of the proximal colon. The percent­ages in Figure 57-4 indicate an increased incidence of cancer in the proximal sections of the large intestine in the last 20 years.

Colorectal cancer can metastasize by means of direct ex­tension or by spreading through the blood or lymph. The tu­mor may spread locally into the four layers of the bowel wall and into neighboring organs. The tumor may enlarge into the lumen of the bowel or spread through the lymphatics or the circulatory system. The circulatory system is entered directly from the primary tumor through blood vessels in the bowel or via the lymphatics. The liver is the most frequent site of metas­tasis from circulatory spread. Of clients with colorectal cancer, 15% to 30% will develop metastasis to the liver in spite of sur­gical resection of the tumor. Metastasis to the lungs, brain, bones, and adrenal glands may also be found. Colon tumors can also spread by peritoneal seeding during surgical resection of the tumor. Seeding occurs when a tumor is excised and can­cer cells break off from the tumor into the peritoneal cavity.

Complications related to the increasing growth of the tumor locally or through metastatic spread include bowel obstruction or perforation with resultant peritonitis, abscess formation, and fistula formation to the urinary bladder or the vagina. The tumor may invade neighboring blood vessels and cause frank bleeding. A tumor growing into the bowel lumen can gradually obstruct the intestine and eventually block it completely. Tu­mor extending beyond the bowel wall may place pressure oeighboring organs (uterus, urinary bladder, and ureters) and cause symptoms that mask those of the cancer. Twenty percent of clients diagnosed with colorectal cancer are diagnosed at the time of an emergency hospitalization for bowel obstruction or other life-threatening complication (Hardcastle, 1997).

Etiology

Risk factors for the development of colorectal cancer include genetic predisposition, personal and dietary factors, and in­flammatory bowel disease.

  GENETIC PREDISPOSITION

Individuals with a first-degree relative diagnosed with colorec­tal cancer have a threefold to fourfold risk of developing the disease. An autosomal dominant inherited genetic disorder known as familial adenomatous polyposis (FAP) accounts for 1% of colorectal cancers. In these individuals, thousands of adenomatous polyps develop over the course of 10 to 15 years and have a 100% chance of becoming malignant. By the age of 20, most individuals require surgical intervention to prevent cancer. Hereditary nonpolyposis colorectal cancer (HNPCC) is another autosomal dominant disorder and accounts for 10% of all colorectal cancers. This disorder is characterized by the de­velopment of colorectal cancer at an average age of 45 years (Cavalieri & Franklin, 1998; Saddler & Ellis, 1999). Clients with this type of genetic disorder may also have a higher inci­dence of endometrial, ovarian, and ureteral cancers.

 PERSONAL FACTORS

Approximately 75% of all colorectal cancers have no known predisposing cause. Age is considered a risk factor in the de­velopment of colorectal cancer, since 95% of cases are diag­nosed in persons over 50 years of age. Individuals who have been diagnosed and treated for colorectal cancers have an in­creased risk of developing a second primary colorectal cancer, often at the site of the surgical anastomosis. Individuals with adenomatous polyps are at an increased risk of developing colorectal cancer. Such individuals need regular follow-up with colonoscopy to visualize and remove polyps.

 DIETARY FACTORS

It is theorized that decreased bowel transit time and certain foods containing chemical mutagens may place individuals at risk for colorectal cancer (Table 57-1). These foods also aid in decreasing bowel transit time, which would increase the time that the bowel is exposed to carcinogens (cancer-causing sub­stances). A high-fat diet, particularly animal fat from red meats, increases bile acid secretion and anaerobic bacteria, which are thought to be carcinogenic within the bowel. Fried and broiled meats and fish are also thought to contain chemical mutagens that are carcinogenic. Diets with large amounts of refined car­bohydrates that lack fiber decrease bowel transit time.

 

COLLABORATIVE MANAGEMENT

 Assessment

 HISTORY

In taking a history from a client with colorectal cancer, the nurse obtains the client’s diet history and asks about major risk factors, such as a personal history of breast, ovarian, or en-dometrial cancer; ulcerative colitis; Crohn’s disease; familial polyposis; or adenomas; or a family history of colorectal can­cer. The nurse also assesses the client’s participation in age-spe­cific screening guidelines for colorectal cancer (Chart 57-2).

The nurse also asks about changes in bowel habits, such as diarrhea or constipation, with or without blood in the stool. The client may also report fatigue (related to anemias), ab­dominal fullness, pain, or weight loss, which, unfortunately, are signs of advanced disease.

 INFLAMMATORY BOWEL DISEASE

Inflammatory bowel diseases, such as ulcerative colitis and Crohn’s disease, pose an increased risk of colorectal cancer, especially if the disease has had a long, severe course.

 Incidence/Prevalence

Americans have a 6% lifetime risk of developing colorectal cancer. Approximately 130,000 people in the United States were diagnosed with colorectal cancer in 1999, with an esti­mated 55,000 deaths (Landis et al., 1999). Most clients with colorectal cancer are older than 50 years of age; only 2% to 6% are younger than 40 years of age. The peak incidence of colorectal cancer occurs in the sixth decade of life. The over­all incidence of colorectal cancer is equivalent in men and women, with cancer of the rectum being more common in men. Anal cancers account for approximately 4% of colorec­tal cancers.

1     PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

The signs of colorectal cancer depend on the location of the tumor. However, the most common signs are rectal bleeding, anemia, and a change in the stool. Stools may contain micro­scopic amounts of blood that are not noticeably visible, or the client may have mahogany-colored or bright red stools. Gross blood is not usually detected with tumors of the right side of the colon but is common (but not massive) with tumors of the left side of the colon and the rectum.

Tumors arising in the transverse and descending colon re­sult in symptoms of obstruction as growth of the tumor im­pedes the passage of stool. The client may complain of “gas pains,” cramping, or incomplete evacuation. Tumors arising in the rectosigmoid colon are associated with hematochezia (the passage of red blood via the rectum), straining to pass stools, and narrowing of stools. Clients may complain of dull pain.

 CULTURAL CONSIDERATIONS

Both male and female African Americans have an in­creased frequency of colorectal cancer in advanced stages at the time of diagnosis, and consequently an increase in death rates from colorectal cancer, as opposed to male and female Caucasian Americans (Saddler & Ellis, 1999). The incidence of colorectal cancer is higher in industrialized regions of the world, with the highest rates found in North America and Australia.

TABLE 57-1      FOODS THAT AFFECT A PERSON’S RISK FOR COLORECTAL CANCER

FOODS TO AVOID

•  Red meat

•  Animal fat

•  Fatty foods

•  Fried or broiled meats and fish

•  Refined carbohydrates (e.g., concentrated sweets)

FOODS TO CONSUME

•  Fruits and vegetables, especially cruciferous vegetables
from the cabbage family (e.g., broccoli, cabbage, cauli­
flower, brussels sprouts)

•  Whole-grain products

•  Adequate fluids, especially water

 

  PSYCHOSOCIAL ASSESSMENT

The psychologic consequences associated with a diagnosis of colorectal cancer are many. Clients must cope with a di­agnosis that inspires fear and anxiety about treatment, pain, possible disfigurement, and a shortened life span. In addi­tion, if the cancer is believed to have a genetic origin, there is anxiety concerning implications for the client’s immediate family members. Possible loss of health insurance and ex­cessive costs of genetic testing are also sources of fear and anxiety.

 LABORATORY ASSESSMENT

COMPLETE BLOOD COUNT AND BLOOD CHEMISTRIES. Hemoglobin and hematocrit values are usually decreased as a result of the intermittent bleeding as­sociated with the tumor. Colorectal cancer that has metasta-sized to the liver will cause liver function tests to be elevated.

FECAL OCCULT BLOOD TESTS. A positive test re­sult for occult blood in the stool (fecal occult blood test

[FOBT]) confirms bleeding in the gastrointestinal (GI) tract. False-positive reactions can be caused by a number of foods and medications. The client avoids meat, peroxidase-containing foods (horseradish and beets), aspirin, and vitamin C for 48 hours before giving a stool specimen. The nurse assesses whether the client is taking anti-inflammatory drugs (such as ibuprofen, corticosteroids, or salicylates). These medications may be discontinued for a period before the test to reduce the risk of a false-positive result (Held-Warmkessel, 1998). Two separate stool samples should be tested on 3 consecutive days. Negative results do not completely rule out the possibility of colorectal cancer.

ONCOFETAL ANTIGEN TESTING. Carcinoembry-onic antigen (CEA) may be elevated in 70% of people with colorectal cancer. There is no relationship between the CEA level and the cancer stage. CEA is not specifically associated with the colorectal cancer, and it may be elevated in the pres­ence of other benign or malignant diseases and in smokers. CEA is often used to monitor the effectiveness of treatment and identify disease recurrence.

 RADIOGRAPHIC ASSESSMENT

BARIUM ENEMA. A double-contrast barium enema (air and barium are instilled into the colon) provides better vi­sualization of polyps and small lesions than barium alone. This test may demonstrate an occlusion in the bowel, where the tumor is decreasing the size of the lumen.

COMPUTED TOMOGRAPHY. Computed tomogra­phy (CT) of the abdomen, pelvis, lungs, or liver helps confirm the existence of a mass and the extent of disease.

CHEST X-RAY STUDY. A chest x-ray study and liver scan may locate distant sites of metastasis.

 CRITICAL THINKING CHALLENGE

You are gathering the initial history for a 44-year-old woman admitted to your unit with intermittent rectal bleeding over the last 3 months. The client states that her maternal un­cle died of colorectal cancer at the age of 52.

•  What personal factors place this client at risk for colorectal cancer?

•  What specific questions would you ask concerning the rectal bleeding she reports?

•  What abnormalities in laboratory values would you suspect?

 OTHER DIAGNOSTIC ASSESSMENT

SIGMOIDOSCOPY. A sigmoidoscopy provides visual­ization of the lower colon using a fiberoptic scope. Polyps can be visualized, and samples can be taken for biopsy.

COLONOSCOPY. A colonoscopy provides visualization of the entire large bowel from the rectum to the ileocecal valve. As with sigmoidoscopy, polyps can be visualized and removed, and tissue samples can be taken for biopsy. Colonoscopy is the definitive test for the diagnosis of colorectal cancer.

LIVER SCAN. A liver scan may locate distant sites of metastasis.

 Analysis

COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

The priority nursing diagnosis for clients with colorectal can­cer is Anticipatory Grieving related to the diagnosis of a po­tentially terminal illness, a disturbance in body image, and the possible loss of fecal continence. The priority collaborative problem is Potential for Metastasis.

■     ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

In addition to the commoursing diagnoses and collabora­tive problems, clients with colorectal cancer may develop one or more of the following:

•  Acute Pain or Chronic Pain related to tumor obstruction of the intestine, with possible pressure on other organs

•  Disturbed Body Image related to the creation of a stoma or fear of incontinence

•  Compromised Family Coping related to alteration in roles, lifestyle changes, and fear of the client’s death

•  Imbalanced Nutrition: Less Than Body Requirements related to the diagnostic workup Fear related to the disease process

•   Powerlessness related to the presence of a life-threaten­ing illness and its treatment

Planning and Implementation

IANTICIPATORY GRIEVING

PLANNING: EXPECTED OUTCOMES. A client faced with a diagnosis of colorectal cancer experiences feel­ings and anxieties that can tax his or her ability to cope with present and future issues related to the disease and treatment. The client with colorectal cancer is expected to identify, de­velop, and use effective coping methods in dealing with the perceived changes and losses experienced.

INTERVENTIONS. The client and family are faced with a possible loss of or alteration in body functions. Medical and surgical interventions for the treatment of colorectal cancer may result in cure, disease control, or palliation. Interventions are designed to assist the client in formulating effective strategies for expressing feelings of grief and developing cop­ing skills.

The nurse observes and identifies the following:

·        The client’s and family’s current methods of coping

·        Effective sources of support used in past crises

·        The client’s and family’s present perceptions of the health problem

·        Signs of anticipatory grief, such as crying, anger, and withdrawal from usual relationships

The nurse encourages the client to verbalize feelings about the diagnosis, treatment, and anticipated alteration in body functions if a colostomy is planned (see later discussion of the operative procedure under Surgical Management, p. 1249). Sadness, anger, feelings of loss, and depression are normal re­sponses to this change in body functions.

If a colostomy is planned, the nurse teaches the client what to expect about the appearance and care of the colostomy. Postoperatively, the client is encouraged to look at and touch the stoma. When the client is physically able, the nurse asks him or her to participate in colostomy care. Participation helps to restore the client’s sense of control over his or her lifestyle and thus facilitates improved self-esteem.

 GRIEF WORK FACILITATION. The purpose of grief work is to assist the client with the resolution of a significant loss. The nurse assists in identifying the nature of and reaction to the loss. Encouraging the client to verbalize feelings and iden­tify fears helps to move him or her through the appropriate phases of the grief process. The nurse establishes a trusting, ongoing relationship with the client and provides support through the personal grieving stages.

The nurse, in collaboration with the psychologist when ap­propriate, assists the client in identifying personal coping strategies. The client is encouraged to implement cultural, re­ligious, and social customs associated with the loss and to identify sources of community support available to the client and family. Modifications in lifestyle can be anticipated in clients with a diagnosis of colorectal cancer. The nurse assists in identifying the necessary modifications in lifestyle that may be necessary. The chaplain, social worker, and/or family assists in discussions and decisions concerning treatment, the prognosis, and end-of-life decisions, as appropriate.

 GENETIC COUNSELING. Genetic counseling entails the use of an interactive helping process focusing on the preven­tion of a genetic disorder or on the ability to cope with a fam­ily member who has a genetically based disorder. The nurse may be asked to provide a referral to a genetics center by clients who are believed to have familial colorectal cancers. Specially trained nurses can discuss the purposes and goals of genetic testing. Privacy and confidentiality need to be ensured. A review of the family history may provide important infor­mation concerning the pattern of colorectal cancer inheritance. To make an informed decision, the client and family need in­formation about the advantages, risks, and costs of appropriate genetic tests. The nurse will need to carefully monitor the client’s response on learning of his or her genetic risk factors.

NIC interventions are summarized in Chart 57-3.

 POTENTIAL FOR METASTASIS

PLANNING: EXPECTED OUTCOMES. The client with colorectal cancer is expected to not have the cancer spread to vital organs; thus the client’s life expectancy will be increased and the quality of life will be improved.

INTERVENTIONS. Although surgical resection is the primary means used to control the disease, several adjuvant therapies are employed as well. Adjuvant therapies are ad­ministered before or after surgery to affect a cure and to pre­vent recurrence.

NONSURGICAL MANAGEMENT. The type of therapy used is based on the pathologic staging of the disease. Dukes’ staging classification is most often used. This method classi­fies colorectal tumors by designating them as either A, B, C, or D according to the depth of invasion into the mucosa and distant spread.

Dukes’ stage A indicates that the tumor has penetrated into, but not through, the bowel wall. Stage B indicates that the tumor has penetrated through the bowel wall. Stage C in­dicates that the tumor has penetrated through the bowel wall and that there is lymph node involvement. Stage D indicates that the tumor has metastasized to any of a number of distant sites.

RADIATION THERAPY. The administration of preopera-tive radiation therapy has not improved overall survival from colorectal cancer but has been effective in providing local or regional control of the disease. Postoperative radiation has not demonstrated any consistent improvement in survival or recur­rence. As a palliative measure, radiation therapy may be used to control pain, hemorrhage, bowel obstruction, or metastasis to the lung in advanced disease. Unlike the case with colorec­tal cancer, radiation therapy is almost always a part of the treatment plan for rectal cancer. The nurse explains the radia­tion therapy procedure to the client and family and monitors for possible side effects (e.g., diarrhea and fatigue). (See Chap­ter 25 for care of clients undergoing radiation therapy.)

CHEMOTHERAPY. Adjuvant chemotherapy after primary surgery is recommended for clients with stage II (Dukes’ stage B₂) or stage III (Dukes’ stage C) disease to improve survival. The drug of choice is intravenous (IV) 5-fluorouracil (5-FU) with or without levamisole or leucovorin. The side effects of 5-FU and levamisole or leucovorin are diarrhea, mucositis, and skin effects. Oxaliplatin is a relatively new platinum analog chemotherapeutic agent. It has been used with 5-FU and lev­amisole or leucovorin with good results in clients with metasta­tic disease. The dose-limiting toxicity for this agent is periph­eral sensory neuropathy.

In 1997 irinotecan (Camptosar) was approved as second-line treatment for metastatic disease if disease has recurred or progressed after treatment with 5-FU. With this drug, myelo-suppression (bone marrow suppression) and diarrhea are the most frequent dose-limiting toxicities. Current clinical trials using a 17-1A monoclonal antibody and a colorectal tumor vaccine are in progress. In addition, new oral agents consist­ing of a fluorinated pyrimidine and leucovorin are being tested. Intrahepatic arterial chemotherapy, often with 5-FU, may be administered to clients with liver metastasis.

SURGICAL MANAGEMENT. Surgical removal of the tu­mor with margins free of disease is the best method of ensuring removal of colorectal cancer. The size of the tumor, its location, the extent of metastasis, the integrity of the bowel, and the con­dition of the client determine which surgical procedure is per­formed for colorectal cancer (Table 57-2). Because the major­ity of colorectal cancers are diagnosed when the cancer has extended beyond the tumor, the three most common surgeries performed are hemicolectomy (resection of the tumor and re­gional lymph nodes) with reanastomosis, colon resection with colostomy (temporary or permanent), and abdominoperineal resection (Saddler & Ellis, 1999).

Small tumors indicate an early stage of cancer and are well differentiated without evidence of vascular or lymphatic inva­sion. They can be removed with clean margins and may be treated with local excision and close follow-up. A transanal approach without an abdominal incision is the technique most commonly used; this approach decreases the risk for postop­erative complications and shortens the hospital stay. Only 5% of clients with colorectal cancer, however, meet the criteria of early-stage cancer. Currently, clinical trials are being con­ducted to evaluate the use of laparoscopic techniques in the treatment of colorectal cancer.

HEMICOLECTOMY    AND     COLON    RESECTION.

A hemicolectomy involves excision of the involved area of the colon, leaving an area of clean margins. If the integrity of the in­testine is optimal (e.g., without inflammation, as with bowel ob­struction or perforation), and if the rectal sphincter can be left in­tact, reanastomosis can usually be accomplished and an ostomy can be avoided. If healing of a reanastomosed bowel is thought to be in jeopardy, a temporary or permanent colostomy will be performed. A colostomy is the surgical creation of an opening of the colon onto the surface of the abdomen.

Preoperative Care. The nurse helps the client to prepare for colon resection by reinforcing the physician’s explanation of the planned surgical procedure. The client is told as accu­rately as possible what anatomic and physiologic changes will occur with surgery. The location and number of incision sites and drains are also discussed.

Before evaluating the tumor and colon during surgery, the physician may not be able to determine whether a colostomy will be necessary. If this is the case, the physician informs the client that a colostomy is a possibility. If the surgeon informs the client that a colostomy is inevitable, the nurse consults an enterostomal therapist (ET) to advise on optimal placement of the ostomy and instructs the client about the rationale and general principles of ostomy care. An ET is a registered nurse who has completed specialized training and is certified in os­tomy nursing care. Some are also certified in wound and in­continence care.

 

SURGICAL PROCEDURES FOR COLORECT/

CANCERS IN VARIOUS LOCATIONS

RIGHT-SIDED COLON TUMORS

•  Right hemicolectomy for smaller lesions

•  Right ascending colostomy or ileostomy for large, wide­
spread lesions

•  Cecostomy (opening into the cecum with intubation to de­
compress the bowel)

LEFT-SIDED COLON TUMORS

•  Left hemicolectomy for smaller lesions

•  Left descending colostomy for larger lesions (e.g., the
Hartmann procedure)

SIGMOID COLON TUMORS

•  Sigmoid colectomy for smaller lesions

•  Sigmoid colostomy for larger lesions (e.g., the Hartmann
procedure)

•  Abdominoperineal resection for large, low sigmoid tumors
(near the anus) with colostomy (the rectum and the anus
are completely removed, leaving a perineal wound)

RECTAL TUMORS

•  Resection with anastomosis or pull-through procedure
(preserves anal sphincter and normal elimination pattern)

•  Colon resection with permanent colostomy

•  Abdominoperineal resection with colostomy

The client who requires low rectal surgery is faced with the risk of postoperative sexual dysfunction and urinary inconti­nence as a result of nerve damage during surgery. The physi­cian discusses the risk for these problems with the client be­fore surgery and allows him or her to verbalize concerns and questions related to this risk. The nurse reinforces teaching about abdominal surgery performed with the client under gen­eral anesthesia and reviews the routines for turning and deep breathing (see Chapter 17).

If the bowel is not obstructed or perforated, elective surgery is planned. The client receives a thorough cleaning of the bowel, or “bowel prep,” to minimize bacterial growth and pre­vent complications. In preparation for the bowel prep, the client is usually instructed to restrict the diet to clear liquids for 1 to 2 days before surgery. Mechanical cleaning is accom­plished with laxatives and enemas or with “whole-gut lavage.” For whole-gut lavage, the client usually ingests large quanti­ties of a sodium sulfate and polyethylene glycol solution (e.g., GoLYTELY). This solution overwhelms the absorptive capac­ity of the small bowel and clears feces from the colon.

To reduce the risk of infection, the surgeon may prescribe oral or IV antibiotics to be given the day before surgery

(Held-Warmkessel, 1998). Before surgery, a nasogastric (NG) tube is placed for decompression of the stomach following surgery. A peripheral IV line is also placed for fluid and elec­trolyte replacement while the client is taking nothing by mouth (NPO).

The client with colorectal cancer faces a serious illness with long-term consequences of the disease and treatment. A case manager can be very helpful in identifying client and family needs, as well as continuity of care and support.

Operative Procedure. The surgeon makes an incision in the abdomen and explores the abdominal cavity to determine if the tumor can be removed. The portion of the colon with the tumor is excised, and the two open ends of the bowel are irri­gated before anastomosis (reattachment) of the colon. If an anastomosis is not feasible because of the location of the tu­mor or the bowel is inflamed, a colostomy is created.

A colostomy may be created in the ascending, transverse, descending, or sigmoid colon (Figure 57-5). One of three ba­sic techniques is used to construct a colostomy. A loop stoma (surgical opening) is made by bringing a loop of colon to the skin surface, severing and everting the anterior wall, and su­turing it to the abdominal wall. Loop colostomies are usually performed in the transverse colon and are usually temporary (Bradley & Pupiales, 1997). An external rod is used to support the loop until the intestinal tissue adheres to the abdominal wall. Care must be taken to avoid displacing the rod, espe­cially during appliance changes.

An end stoma is often constructed, most often in the de­scending or sigmoid colon, when a colostomy is intended to

 

be permanent. It may also be done in conjunction with a Hartmann procedure, when the surgeon oversews the distal stump of the colon and places it in the abdominal cavity, pre­serving it for future reattachment. An end stoma is con­structed by severing the end of the proximal portion of the bowel and bringing it out through the abdominal wall.

The least common colostomy is the double-barrel stoma, which is created by dividing the bowel and bringing both the proximal and distal portions to the abdominal surface to cre­ate two stomas. The proximal stoma (closest to the client’s head) is the functioning stoma and eliminates stool; the distal stoma (farthest from the head) is considered nonfunctioning, although it may secrete some mucus. The distal stoma is sometimes referred to as a mucous fistula.

Postoperative Care. Clients who have undergone a colon resection without a colostomy receive care similar to that of clients undergoing any abdominal surgery (see Chapter 19).

Colostomy Management. The client who has a colostomy created may return from surgery with an ostomy pouch sys­tem in place. If there is no pouch system in place, a petrola­tum gauze dressing is usually placed over the stoma to keep it moist, and this is covered with a dry, sterile dressing. In col­laboration with the enterostomal therapist (ET), the nurse places a pouch system as soon as possible. The colostomy pouch system allows more convenient and acceptable collec­tion of stool than a dressing does.

The nurse assesses the color and integrity of the stoma. A healthy stoma should be reddish pink and moist and will pro­trude about ³/₄ inch (2 cm) from the abdominal wall. A small amount of bleeding at the stoma is common.

The nurse reports any of the following problems related to the colostomy to the surgeon:

·        Signs of ischemia and necrosis (dark red, purplish, or black color; dry, firm, or flaccid)

·        Unusual bleeding

·        Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal wall)

The nurse also assesses the condition of the peristomal skin and frequently checks the pouch system for proper fit and signs of leakage. The peristomal skin should be intact, smooth, and without redness or excoriation.

The colostomy should start functioning 2 to 4 days postoper-atively. When the colostomy begins to function, the pouch may need to be emptied frequently because of excess gas collection. It should be emptied when it is one-third to one-half full of stool. Stool is liquid immediately postoperatively but becomes more solid, depending on where in the colon the stoma was placed. For example, the stool from a colostomy in the ascending colon is liquid, the stool from a colostomy in the transverse colon is pasty, and the stool from a colostomy in the descending colon is more solid (similar to usual stool expelled from the rectum).

ABDOMINOPERINEAL RESECTION. When rectal tu­mors are present, the rectum and rectal support structure may need to be removed. An abdominoperineal resection usually requires a permanent colostomy for evacuation. However, with improvements in surgical techniques, more clients can undergo a colon resection with the rectal sphincter left intact; thus the need for a colostomy is avoided.

Preoperative Care. The preoperative care for the client undergoing an abdominoperineal resection is similar to that provided for the client undergoing a colon resection.

Operative Procedure. The surgeon removes the distal sigmoid colon, the rectosigmoid colon, the rectum, and the anus through combined abdominal and perineal incisions. A permanent end-sigmoid colostomy is created.

Postoperative Care. Postoperative care after an ab­dominoperineal resection is similar to that given after a colon resection with the creation of a sigmoid colostomy. The nurse collaborates with the ET to provide colostomy care and client and family education. In addition, the nurse monitors for post­operative complications, including pneumonia, dehydration, anastomotic leakage, and wound infection.

Wound Management. The perineal wound is generally sur­gically closed, and two bulb suction drains, such as Jackson-Pratt drains, are placed in the wound or through stab wounds near the wound. The drains help prevent drainage from col­lecting within the wound and are usually left in place for sev­eral days, depending on the character and amount of drainage.

Monitoring drainage from the perineal wound and cavity is important because of the possibility of infection and abscess formation. Serosanguineous drainage from the perineal wound may be observed for 1 to 2 months after surgery. Com­plete healing of the perineal wound may take 6 to 8 months. This wound can be a greater source of discomfort than the ab­dominal incision and ostomy, and more care may be required. The client may experience phantom rectal sensations because sympathetic innervation for rectal control has not been inter­rupted. Rectal pain and itching may occasionally occur after healing; however, there is no known physiologic explanation for these sensations. Interventions may include use of an-tipruritic medications, such as benzocaine, and sitz baths. The nurse continually assesses for signs of infection, abscess, or other complications and implements methods for promoting wound drainage and comfort (Chart 57-4).

Colostomy Management. The care of the permanent colostomy created as a result of the abdominal-perineal resection is similar to that of a hemicolectomy with a colostomy (see Surgical Management, p. 1249).

HEALTH TEACHING

Before discharge, clients are instructed to avoid lifting heavy objects or straining on defecation to prevent tension on the anastomosis site. The client is advised to avoid driving for 4 to 6 weeks while the incision heals. A stool softener may be prescribed to keep stools at a soft consistency for ease of pas­sage. Clients are instructed to note the frequency, amount, and character of the stools. In addition to this information, the nurse teaches all clients with colon resections to watch for and report clinical manifestations of intestinal obstruction and perforation (e.g., cramping, abdominal pain, nausea, and vomiting). A normal diet may be resumed; however, the client is advised to avoid gas-producing foods and carbonated bev­erages. Four to six weeks may be required to establish the ef­fects of certain foods on bowel patterns.

COLOSTOMY CARE. Rehabilitation after ostomy sur­gery requires that clients and family members learn the prin­ciples of colostomy care and the psychomotor skills needed to facilitate this care. Providing information is important, but the nurse must also allow adequate opportunity for clients to learn the psychomotor skills involved in ostomy care before discharge. Sufficient practice time is planned for clients and family or significant others so that they can handle, assemble, and apply all ostomy equipment. The nurse teaches clients and family or other caregiver about the following:

·        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

·        • Dietary measures to control gas and odor

·        Resumption of normal activities, including work, travel, and sexual intercourse

The appropriate pouch system must be selected and fitted to the stoma. Clients 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. Clients 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 (Bradley & Pupiales, 1997). This type of system presses into the skin around the stoma, causing the stoma to protrude. This protrusion helps tighten the skin and prevents leaks around the stoma opening onto the peristomal skin.

Measurement of the stoma is necessary to determine the correct size of the stomal opening on the appliance. 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 of surgery; therefore it needs to be mea­sured at least once weekly during this time and as needed if the client gains or loses weight. The client and family caregiver should be taught to trace the pattern of the stomal area on the wafer portion of the appliance and to cut an opening about !/₈ to ‘/₁₆ inch larger than the stomal pattern to ensure that stomal tissue will not be constricted (Catanzaro & Serembus, 1998).

Skin preparation may include clipping peristomal hair or shaving the area to achieve a smooth surface, prevent unnec­essary discomfort when the wafer is removed, and minimize the risk of infected hair follicles. The client is advised to avoid using moisturizing soaps to clean the area because the lubri­cants can interfere with adhesion of the appliance. The client and family caregiver are taught to apply a skin sealant and al­low it dry before application of the appliance (colostomy bag) to facilitate less painful removal of the tape or adhesive. If peristomal skin becomes raw, the client or caregiver checks to see whether the sealant contains alcohol and, if so, reconsid­ers using it to avoid causing a burning sensation to the skin. Stoma powder or paste, or a combination, may also be used for erythematous peristomal skin. The paste is also used to fill in crevices and creases to create a flat surface for the faceplate of the colostomy bag. If the client develops a fungal rash, an antifungal cream or powder is used, as ordered.

Control of gas and odor from the colostomy is often a sig­nificant goal for clients with new ostomies. Although a leaking or inadequately closed pouch is the usual cause of odor, flatus can also contribute to the odor. The nurse teaches the client and family caregiver that although there are generally no forbidden foods for ostomates, certain foods and habits can cause flatus or contribute to odor when the pouch is open. Broccoli, brus-sels 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 will help prevent odor; charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch will eliminate odors. The client should be cautioned not to put aspirin tablets in the pouch because they may cause ulceration of the stoma (Table 57-3).

The client with a sigmoid colostomy may benefit from colostomy irrigation to regulate elimination. However, most clients with a sigmoid colostomy can become regulated through diet. An irrigation is similar to an enema but is ad­ministered through the stoma rather than the rectum.

In addition to instructing the client about the clinical mani­festations of obstruction and perforation, the nurse also ad­vises the client with a colostomy to report any fever or sudden onset of pain or swelling around the stoma. Other assessments performed by the home care nurse are listed in Chart 57-5.

PSYCHOSOCIAL PREPARATION. The diagnosis of cancer can be emotionally immobilizing for the client and family or significant others, but treatment may be welcomed because it may provide hope for control of the disease. The nurse explores the client’s reactions to the illness and percep­tions of planned interventions.

The client’s reaction to ostomy surgery, which may include disfigurement, may involve the following:

•  Fear of not being accepted by others

•  Feelings of grief related to disturbance in body image

•  Concerns about sexuality

The nurse allows the client to verbalize his or her feelings. By teaching how to physically manage the ostomy, the nurse can help the client begin to restore self-esteem and improve body image. Inclusion of family and significant others in the rehabilitation process may help maintain relationships and raise the client’s self-esteem. Anticipatory instruction in­cludes information on leakage accidents, odor control mea­sures, and adjustments to resuming normal sexual relation­ships.

INTESTINAL OBSTRUCTION

OVERVIEW

Intestinal obstruction is defined as “a partial or complete ob­struction of the small or large bowel that impedes the natural progression of digestive processing” (Shelton, 1999, p. 478). In­testinal obstruction is a common and serious disorder caused by a variety of conditions and is associated with significant mor­bidity. Bowel obstruction accounts for up to 20% of emergency admissions to a surgical service. It can occur anywhere in the in­testinal tract, although the ileum in the small intestine (the nar­rowest part of the intestinal tract) is the most common site. The nurse assesses for clinical manifestations of obstruction in all clients with gastrointestinal (GI) disorders, since obstruction oc­curs fairly often and is associated with a variety of conditions.

Pathophysiology

Intestinal obstructions can be partial or complete and are clas­sified as mechanical or nonmechanical. In mechanical ob struction, the bowel is physically obstructed by disorders outside the intestine (e.g., adhesions or hernias) or by block­ages in the lumen of the intestine (e.g., tumors, inflammation, strictures, or fecal impactions). Nonmechanical obstruction (also known as paralytic ileus or adynamic ileus because it is a result of neuromuscular disturbance) does not involve a physical obstruction d or absent, resulting in a slowing of the movement or a backup of intestinal contents.

 

 Etiology

Mechanical obstruction can result from adhesions, tumors, hernias, fecal impactions, strictures due to Crohn’s disease or radiation, intussusception (telescoping of a segment of the in­testine within itself), volvulus (twisting of the intestine), fi-brosis due to disorders such as endometriosis, and vascular disorders (e.g., emboli and arteriosclerotic narrowing of mesenteric vessels) (Figure 57-6). In individuals age 65 or older, diverticulitis and tumors are the most common causes of obstruction.

Regardless of age, adhesions are the most common cause of mechanical obstruction, accounting for 45% to 60% of cases. Adhesions are bands of granulation and scar tissue that develop as a result of an inflammatory response, encircling the intestine and constricting its lumen.

Paralytic, or adynamic, ileus is a nonmechanical obstruc­tion caused by physiologic, neurogenic, or chemical imbal­ances associated with decreased peristalsis from trauma or the effect of a toxin on autonomic intestinal control. Adynamic ileus occurs to some degree following abdominal surgery or trauma. Paralytic ileus can be caused by handling of the in­testines during abdominal surgery; intestinal function is lost for a few hours to several days.Thoracic diseases such as myocardial infarction, rib frac­ture, and pneumonia can also cause paralytic ileus. Electrolyte disturbances, especially hypokalemia, predispose the client to ileus. Paralytic ileus can be a consequence of peritonitis, since leakage of colonic contents causes severe irrita­tion and triggers an inflammatory response. Vascular insufficiency to the bowel, also referred to as intestinal ischemia, is a potential cause of adynamic ileus. Vascular insufficiency results when arterial or venous thrombosis or an embolus de­creases blood flow to the mesenteric blood vessels surrounding the intestines, as in congestive heart failure or severe shock. Severe insufficiency of blood supply can result in in­farction of surrounding organs (e.g., bowel infarction).

 Incidence/Prevalence

Obstruction of the intestines occurs in approximately 20% of all clients who are seen for acute abdominal pain. It is the most common reason for surgery of the small intestine. Be­cause bowel obstruction is a result of other disorders, statis­tics on the incidence of bowel obstruction are not readily available.

Obstruction of the intestines occurs in all age-groups, but the incidence differs with age. In adults, 75% of all obstructions occur in the small intestine and 15% occur in the large intestine. In order of occurrence, adhesions, hernias, and tu­mors are the most common causes of small-bowel obstruc­tion; cancer of the colon, diverticulitis, and volvulus cause most large-bowel obstructions in adults.

 CONSIDERATIONS FOR OLDER ADULTS

CfflfflThe physiologic changes associated with aging, such as decreased peristalsis and decreased mobility, contribute to fecal impactions in older adults. Fecal impactions can lead to partial or complete bowel obstruction.

COLLABORATIVE MANAGEMENT

 Assessment

 HISTORY

The nurse collects information concerning the following:

·        Past or recent abdominal surgery

·        Radiation therapy

·        History of inflammatory bowel disease

·        Gallstones

·        Hernias

·        Trauma

·        Peritonitis

·        Cancer

The client is asked about recent occurrence of nausea or vomiting. The nurse also asks about the passage of flatus and the time, character, and consistency of the last bowel move­ment. Singultus (hiccups) is common with all types of intes­tinal obstruction.

The nurse assesses for a family history of colorectal cancer and asks the client about blood in the stool or a change in bowel pattern. The body temperature with obstruction is rarely higher than 100° F (37.8° C). A temperature higher than this, with or without guarding and tenderness, and a sus­tained elevation in pulse indicate a strangulated obstruction or peritonitis.

  PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

MECHANICAL OBSTRUCTION. The client with me­chanical obstruction in the small intestine often has mid-abdominal pain or cramping. The pain can be sporadic, and the client may feel comfortable between episodes. 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 vomi-tus may contain bile and mucus or be orange-brown and foul smelling as a result of bacterial overgrowth with low ileal ob­struction. 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 may be pres­ent, as well as obstipation, or 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.

On examination of the abdomen, the nurse may observe abdominal distention, which is common in all forms of intes­tinal obstruction. Peristaltic waves may also be visible. The nurse auscultates 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, the 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.

NONMECHANICAL OBSTRUCTION. In most types of nonmechanical obstruction (paralytic, or adynamic, ileus), the pain is described as a constant, diffuse discomfort. Col­icky cramping is not characteristic of this type of obstruction. Pain associated with obstruction attributable to vascular in­sufficiency or infarction is usually severe and constant. On in­spection, abdominal distention is typically present. On auscontents and bile is frequent, but the vomitus rarely has a foul odor and is rarely profuse. Ob­stipation may or may not be present. Chart 57-6 compares small-bowel and large-bowel obstructions.

 LABORATORY ASSESSMENT

There is no definitive laboratory test to confirm a diagnosis of mechanical or nonmechanical obstruction. White blood cell (WBC) counts may be normal unless there is a strangulated obstruction, in which case there may be leukocytosis (in­creased WBCs). Hemoglobin, hematocrit, creatinine, and blood urea nitrogen (BUN) values are often elevated, indicat­ing dehydration. Serum sodium, chloride, and potassium con­centrations are reduced because of loss of fluid and elec­trolytes. Elevations in serum amylase levels may be found with strangulating obstructions, which can damage the pancreas.

High obstruction in the small intestine is likely to show an el­evated serum venous carbon dioxide concentration and other values indicative of metabolic alkalosis. Obstruction in the large intestine is likely to show a low serum venous carbon dioxide concentration and other values suggestive of metabolic acidosis.

 RADIOGRAPH IC ASSESSMENT

The health care provider obtains flat-plate and upright ab­dominal x-ray films as soon as an obstruction is suspected. Distention of loops of intestine with fluid and gas in the small intestine, in conjunction with the absence of gas in the colon, indicates an obstruction in the small intestine. However, x-ray findings are ofteormal when a strangulated obstruction ac­tually exists in the small intestine. Therefore obstruction can­not be ruled out on the basis of x-ray findings.

Obstruction of the large intestine often shows gas disten­tion of the colon on abdominal x-ray studies. A finding of free air under the diaphragm on abdominal x-ray examination in­dicates a perforated intestine.

 OTHER DIAGNOSTIC ASSESSMENT

The diagnostic examination chosen depends on the suspected location of the obstruction. The physician may perform en-doscopy (sigmoidoscopy or colonoscopy) or a barium enema study to determine the cause of the obstruction, except in cases where perforation is suspected. A computed tomography (CT) scan is useful in uncovering the cause and location of the ob­struction and may be the diagnostic tool of choice when symp­toms are severe (see the Cost of Care Box at right).

 Interventions

Interventions are aimed at uncovering the cause and relieving the obstruction. Intestinal obstructions can be relieved by non-surgical or surgical means. If the obstruction is partial and there is no evidence of strangulation, nonsurgical management is the treatment of choice. Decompression of the intestinal tract is initiated along with fluid and electrolyte replacement.

NONSURGICAL   MANAGEMENT. Paralytic  ileus  re­sponds well to nonsurgical methods of relieving obstruction.Nonsurgical approaches are also preferred in the treatment of clients with terminal disease associated with bowel ob­struction. In addition to being on NPO status, clients with intestinal obstruction typically have a nasogastric or, more rarely, nasointestinal tube inserted. These tubes provide de­compression of the bowel by draining fluid and air and are attached to suction; the type of suction depends on the type of tube inserted.

NASOINTESTINAL TUBES. The physician occasionally inserts nasointestinal (NI) tubes (such as the Miller-Abbott, Cantor, and Harris tubes) for obstruction of the small intestine. These longer tubes extend into the small intestine. Mercury-filled balloons at the end of a lumen act as a bolus of food, stimulating peristalsis and advancing down the intestinal tract. The Cantor and Harris tubes are single-lumen tubes with mer­cury-filled balloons at the tips and suction ports within the same lumen, proximal to the tip. The Miller-Abbott tube has two separate lumens for mercury and drainage.

The nurse assists with progression of the tube by helping the client change position every 2 hours and, if ordered, by advancing the tube 3 to 4 inches at specified times. These tubes are never taped to the nose until they reach a specified position in the intestine. As the tube is being inserted and ad­vanced, it drains by gravity. The nurse monitors the drainage; if drainage stops, the nurse obtains a physician’s order to in­ject 10 mL of air. The nurse does not irrigate the NI tube with fluid without an order by the health care provider. If ordered, the nurse attaches low intermittent suction to the suction lu­men when the tube has stopped advancing.

INTESTINAL OBSTRUCTION

Cost of Care

•  The cost of plain abdominal films in the diagnosis of intes­
tinal obstruction is approximately $200 to $300 and pro­
vides an overall accuracy of 57%.

•  A barium swallow or enema can cost $300 to $500, with an
overall accuracy of 78%.

•  Computed tomography (CT) can cost $500 to $800. The
overall accuracy of CT in diagnosing intestinal obstruction
ranges from 91 % to 97%.

•  The use of ultrasound in the diagnosis of intestinal obstruc­
tion is gaining popularity. The cost of this procedure is $300
to $600, with an overall accuracy of 81 % to 96%.

•  Laparoscopy is indicated to evaluate the need for laparot-
omy. The cost of this procedure can range from $1000 to
$2000, with an overall accuracy of 94%.

NASOGASTRIC TUBES. Most clients with an obstruc­tion have at least a nasogastric (NG) tube in place unless the obstruction is mild. Salem sump and Anderson tubes are ex­amples of NG tubes that sit distally in the stomach and are at­tached to low continuous suction. Levin tubes are connected to low intermittent suction.

At least every 4 hours, the nurse assesses the client with an NG tube for proper placement of the tube, tube patency, and output. The nasal skin is also monitored daily for integrity. The nurse assesses for peristalsis by auscultating for bowel sounds with the suction disconnected (suction will mask peri­staltic sounds).

The nurse questions the client regarding the passage of fla­tus and records the passage, amount, and character of bowel movements daily. Abdominal girth is measured at the same point each day. The client is also assessed for nausea and asked to report this manifestation.

NG tubes must be monitored for proper functioning. Oc­casionally, NG tubes move out of optimal drainage position or become plugged. In this case, the nurse notes a decrease in gastric output or stasis of the tube’s contents. The client is as­sessed for nausea, vomiting, increased abdominal distention, and placement of the tube. If the NG tube is repositioned or replaced, confirmation of proper placement is obtained by x-ray examination before use. After appropriate placement is es­tablished, the contents are aspirated and the tube is irrigated with 30 mL of normal saline every 4 hours or as needed to maintain patency.

OTHER NONSURGICAL TECHNIQUES. Most types of nonmechanical obstruction respond to nasogastric decom­pression in conjunction with medical treatment of the primary disorder. Incomplete mechanical obstruction can sometimes be successfully treated without surgery. Obstruction caused by fecal impaction usually resolves after disimpaction and en­ema administration. Intussusception may respond to hydro­static pressure changes during a barium enema.

FLUID AND ELECTROLYTE REPLACEMENT. IV fluid replacement and maintenance are indicated for all clients with intestinal obstruction, since the client is on NPO status and fluid and electrolyte loss (particularly potassium) through vomiting and nasogastric suction is great. On the basis of serum electrolytes and blood urea nitrogen (BUN) levels, the health care provider orders aggressive fluid replacement with 2 to 4 L of normal saline or lactated Ringer’s solution with potassium added. Care must be taken with clients who are prone to fluid overload (e.g., the client with a history of con­gestive heart failure). The nurse carefully monitors lung sounds, weight, and intake and output parameters. Blood re­placement may be indicated in strangulated obstruction be­cause of blood loss into the bowel or peritoneal cavity.

The nurse or assistive nursing personnel monitors the client’s vital signs and other measures of fluid status (e.g., urine output, skin turgor, and mucous membranes). Edema from third spacing is assessed because fluid is lost, mostly from the vascular space, into surrounding spaces (e.g., the peritoneal cavity). In collaboration with the dietitian, the physician may order total parenteral nutrition (TPN) to im­prove the nutritional status of the client, especially if he or she has had chronic nutritional problems and has been on NPO status for an extended period. Chapter 61 discusses the nurs­ing care of clients receiving TPN.

Because of fluid losses, the client with intestinal obstruc­tion is characteristically thirsty. The nurse provides frequent mouth care to help maintain moist mucous membranes. Lemon-glycerin swabs are avoided because they can increase mouth dryness. A small amount of ice chips may be allowed if the client is not having surgery; however, the health care provider should be consulted first. Ice chips can provide more free water than electrolytes; thus potassium and hydrochloric acid are washed out of the NG tube. The nurse monitors in­take and output carefully to avoid electrolyte imbalance and false interpretation of gastric output measurements.

PAIN MANAGEMENT. The abdominal distention com­monly noted with intestinal obstruction can cause a great deal of discomfort, especially when distention is severe. The col­icky, crampy pain that comes and goes with mechanical ob­struction and the nausea, vomiting, dry mucous membranes, and thirst contribute to the client’s discomfort. The nurse con­tinually assesses the character and location of the pain and immediately reports any pain that significantly increases or changes from a colicky, intermittent type to a constant dis­comfort. Such changes can indicate perforation of the intes­tine or peritonitis.

Opioid analgesics are normally withheld in the diagnostic period so that clinical manifestations of perforation or peri­tonitis are not masked. The nurse explains to the client and family the rationale for not giving analgesics. In addition, if analgesics such as morphine or meperidine are given, they slow intestinal motility and can cause vomiting. The nurse must be alert to this side effect, because nausea and vomiting are also signs of NG tube obstruction or worsening bowel ob­struction.

The nurse helps the client 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. Not only is this a good comfort technique, but it also facilitates adequate thoracic excursion and normal breathing patterns.

Discomfort is generally less with nonmechanical obstruc­tion than with mechanical obstruction. With both types of ob­struction, discomfort is aggravated by ingestion of food or fluids.

DRUG THERAPY. 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, medications that enhance gastric motility, such as oc-treotide acetate (Sandostatin), may be used.

SURGICAL MANAGEMENT. In all cases of complete mechanical obstruction and in many cases of incomplete me­chanical obstruction, surgical intervention is necessary to re­lieve the obstruction. A strangulated obstruction is inevitably complete, and surgical intervention is always required. An ex­ploratory laparotomy (a surgical opening of the abdominal cavity to investigate the cause of the obstruction) is initially performed for most clients with obstruction. More specific surgical procedures depend on the cause of the obstruction.

PREOPERATIVE CARE.

VIDEO

 The nurse provides preoperative teaching as discussed in Chapter 17. If time permits, all clients who require surgery for obstruction undergo nasogastric intu­bation and suction before surgery. However, in cases of com­plete obstruction, surgery should proceed without delay.

OPERATIVE PROCEDURES. The surgeon enters the ab­dominal cavity and explores for obstruction. If adhesions are found to be the cause of the obstruction, the adhesions are lysed (cut and released). Obstruction caused by a tumor or di-verticulitis requires a colon resection with primary anastomo­sis or a temporary or permanent colostomy. If obstruction is caused by intestinal infarction, an embolectomy, thrombec-tomy, or colon resection (partial removal) may be necessary, particularly if the intestine is gangrenous.

POSTOPERATIVE CARE. Postoperative care for the client undergoing an exploratory laparotomy with lysis of ad­hesions, colon resection, thrombectomy, or embolectomy is similar to that described in Chapter 19. AH clients have an NG tube in place until peristalsis (as characterized by the return of bowel sounds) resumes. The NG tube is removed slowly by first discontinuing suction and then clamping the tube for a scheduled amount of time. Residual drainage is checked at each stage to assess peristalsis without decompression before removing the NG tube entirely.

■     HEALTH TEACHING

The nurse instructs the client to report any abdominal pain or distention, nausea, or vomiting, with or without constipation, since these symptoms might indicate recurrent obstruction.

ABDOMINAL TRAUMA

  OVERVIEW

Abdominal trauma is defined as injury to the structures lo­cated between the diaphragm and the pelvis, which occurs when the abdomen is subjected to blunt or penetrating forces. Organs injured may include the large or small bowel, liver, spleen, duodenum, pancreas, kidneys, and urinary bladder.

At least one half of all blunt abdominal trauma occurs from motor vehicle accidents (MVAs) (Sommers & Johnson, 1997). Other causes of blunt trauma include falls, aggravated assaults, and contact sports. Penetrating abdominal trauma is caused by gunshot wounds, stabbing, or impalement with an object. The liver is the most commonly injured organ in blunt and penetrating trauma. The spleen is the most commonly in­jured organ in blunt abdominal trauma. The small intestine is the third most commonly injured organ in abdominal trauma; 80% of injuries are caused by gunshot wounds (GSWs).

 CULTURAL CONSIDERATIONS

 MVAs are three times more common in males than in fe­males in the 15- to 24-year age-group. In the 15- to 34-year age-group, European Americans (Caucasians) have a death rate from MVAs that is 40% higher than that of African Amer­icans (Sommers & Johnson, 1997). Penetrating injuries from GSWs and stab wounds are more common in preteen and young adults than in older adults and are more common in African Americans than in European Americans.

COLLABORATIVE MANAGEMENT

 Assessment

In the emergency phase of treatment, health care providers fo­cus on the risks of hemorrhage, shock, and peritonitis. Men­tal status and skin perfusion are priority nursing assessments, with skin perfusion being the most reliable clinical guide in assessing hypovolemic shock:

·        In a person with mild shock, the skin is pale, cool, and moist.

·        With moderate shock, diaphoresis is more marked and urine output ceases.

·        With severe shock, changes in mental status are manifested by agitation, disorientation, and recent memory loss.

The nurse assesses for abdominal trauma by asking the client about the presence, location, and quality of pain. The abdomen, flanks, back, genitalia, and rectum are inspected for contusions, abrasions, lacerations, ecchymosis, penetrating injuries, and symmetry. All of the client’s clothes must be re­moved. If pneumatic garments such as antishock trousers are in place, they are usually not removed unless aggressive fluid replacement has been given to the client, a surgical team is available to immediately intervene, and the attending physi­cian orders it to be done. After pneumatic garments are re­moved, uncontrolled hemorrhage can occur. Antishock trousers have a constrictive effect on hemorrhage in the trunk and facilitate circulatory return to the heart. However, they can cause compartment syndrome to the lower extremities; consequently, their use is controversial.

Inspection of the abdomen may reveal distention. To perform an adequate inspection, the nurse turns the client while main­taining spinal immobilization. Ecchymosis may signify internal bleeding. Ecchymosis present in the distribution of a lap seat belt should be reported to the health care provider immediately, since investigation for occult injury to the bowel is necessary. Ecchymosis around the umbilicus is known as Cullen’s sign, and ecchymosis on either flank (known as Turner’s sign) may indicate retroperitoneal bleeding into the abdominal wall.

The nurse auscultates 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. The nurse also auscultates for bruits in the abdomen, which indicate renal artery injury.

During percussion, an abnormal sign associated with ab­dominal trauma is resonance over the right flank with the client lying on the left side. This is known as Ballance’s sign and is found with a ruptured spleen. Resonance over the nor­mally dull liver is due to free air, which is pathologic. Palpa­tion for lower rib fractures should increase suspicion of liver or spleen injuries. Injury to the spleen is present in 20% of in­dividuals with left lower rib fractures. Liver injury is present in 10% of individuals with right lower rib fractures. The pres­ence of Kehr’s sign, left shoulder pain resulting from di­aphragmatic irritation, may be present in splenic injury.

Dullness over hollow organs that normally contain gas, such as the stomach and the large and small intestines, may indicate blood or fluid. Light abdominal palpation identifies areas of tenderness, rebound tenderness, guarding, rigidity, and spasm. If the nurse palpates a mass, it may be blood or a fluid collection.

The client without obvious significant bleeding or definite signs of peritoneal irritation undergoes abdominal radiogra­phy, diagnostic peritoneal lavage (DPL), and computed to­mography (CT). For peritoneal lavage, the physician inserts a large-bore catheter into the abdomen and allows fluid to enter the abdominal cavity. If the return drainage from the abdomen is pink or grossly bloody, the health care team prepares the client for surgery. Abdominal ultrasound has recently been used successfully in diagnosing blunt abdominal trauma and may replace CT and DPL for diagnosis (Levins, 2000). Clients with hemodynamic instability or peritonitis are candi­dates for immediate laparotomy.

Interventions

Nonsurgical and surgical interventions are aimed at preserv­ing or restoring hemodynamic stability, preventing or de­creasing blood loss, and preventing complications.

NONSURGICAL MANAGEMENT. 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. The health care provider may insert a central venous catheter to assist with rapid fluid volume infusion. IV fluid consists of a balanced saline solution, crystalloids, and possibly blood.

The following physiologic parameters are monitored: • Arterial blood gases Complete blood count (CBC)

Serum electrolyte, glucose and amylase, and blood urea nitrogen (BUN) determinations Liver function tests Clotting studies

Measuring arterial blood gases may be of assistance in de­termining the severity of shock. Hemoglobin and hematocritvalues 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. All laboratory work is compiled so that values can be compared and subtle changes noted.

Continuous cardiac monitoring is begun in the emer­gency department. The nurse inserts an indwelling urinary (Foley) catheter unless there is blood at the urinary meatus. Initially and hourly thereafter, the nurse evaluates 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, the nurse covers it with a sterile dry dressing unless the physician or­ders otherwise. Unless it is contraindicated, as in the case of a concomitant skull fracture, the physician or nurse in­serts a nasogastric (NG) tube, which is kept in place to identify bleeding and to minimize the risk of vomiting and aspiration. Antibiotics are administered as ordered to re­duce the risk of peritonitis.

If the client with known abdominal trauma has no definite clinical manifestations of active bleeding or abdominal injury, he or she is admitted to the hospital for observation. Blunt trauma can cause active, but ofteot obvious, damage. The nurse assesses for abdominal or referred pain and nausea. Every 15 to 30 minutes in the early postinjury period and then hourly, the nurse evaluates the client’s:

•  Mental status

•  Vital signs

•  Clinical findings, such as vomiting, guarding, rigidity, or rebound tenderness

•  Skin temperature

•  Bowel sounds

•  Urine output

The nurse reports any change immediately to the health care provider. It is more important for the nurse to recognize the high risk of an active abdominal injury and assess for gen­eral signs of abdominal injury (e.g., hemorrhage and peritoni­tis) than to identify the exact nature of the abdominal injury. Analgesics for pain are not prescribed at this time so that clin­ical manifestations are not masked or overlooked. The nurse explains the rationale for withholding analgesics to the client and family or significant others.

SURGICAL MANAGEMENT. For the client with severe abdominal trauma, the surgeon performs an exploratory lap-arotomy and repairs abdominal injuries immediately if there are definite signs of peritoneal irritation. These signs include rebound tenderness, significant blood loss, evisceration, or a gunshot wound (GSW) with possible peritoneal involvement.

Most stab wounds require exploratory laparotomy, but as many as 25% are superficial and do not involve the peri­toneum. Using local anesthesia, the surgeon explores and cleans superficial stab wounds; the client does not require an exploratory laparotomy.

Before discharge from the hospital, the client who has ex­perienced abdominal trauma is taught the signs and symptoms of abdominal bleeding whether or not surgery has been per­formed. The nurse instructs the client to report abdominal pain, nausea, vomiting, bloody or black stools, fever, weak­ness, and dizziness.

Hemorrhage can occasionally occur weeks after blunt ab­dominal trauma, despite medical evaluation. For the client who undergoes surgery or exploration of wounds, the nurse provides instructions on wound care before discharge from the hospital.

POLYPS OVERVIEW

Polyps in the intestinal tract are small growths covered with mucosa and attached to the surface of the intestine. Although most are benign, polyps are significant in that some have the potential to become malignant.

Polyps are identified by their tissue type. The presence of adenomas always necessitates medical consultation because of their malignant potential. Although only 2% to 5% of ade­nomas progress to cancer, almost all colorectal cancers de­velop from an adenoma (Markowitz & Winawer, 1997). Ade­nomas are further classified as villous or tubular. Of these, villous adenomas pose a greater cancer risk.

Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC) are inherited syn­dromes characterized by progressive development of colorec­tal adenomas. Unless these syndromes are treated, colorectal cancer inevitably occurs by the fourth to fifth decade of life (Markowitz & Winawer, 1997).

Other types of polyps include hyperplastic and hamar-tomatous polyps. Hyperplastic polyps, which include mu-cosal and inflammatory varieties, are entirely benign with no malignant potential. Hamartomatous polyps include juvenile and Peutz-Jeghers syndrome polyps. Although both types are generally benign, rare reports of malignant changes have been reported in juvenile polyps.

In addition to being classified by their tissue type, polyps are described according to their appearance (Figure 57-7). Pe-dunculated polyps are stalklike; a thin stem attaches them to the intestinal wall. They become elongated as peristalsis pulls them into the lumen of the intestine. Polyps attached to the in­testinal walls by a broad base are described as sessile. A ma­lignant polyp may be pedunculated or sessile.

 COLLABORATIVE MANAGEMENT

Polyps are usually asymptomatic and are discovered during routine diagnostic testing, including tests for blood in the stool. However, they can cause gross rectal bleeding, intestinal obstruction, or intussusception (telescoping of the bowel). Di­agnostic studies involve a barium enema examination and proctosigmoidoscopy or colonoscopy for ruling out cancer. Biopsy specimens of polyps can be obtained, or the entire polyp can be removed (polypectomy) with the use of an elec-trocautery snare that fits through the sigmoidoscope or colono-scope. This often eliminates the need for abdominal surgery to remove a suspicious or definitely malignant polyp.

The client with FAP often requires a total colectomy (colon removal) to prevent the development of cancer.

Nursing care focuses on client education. The nurse in­structs the client about the following:

•  The nature of the polyp

•  Clinical manifestations to report to the health care provider

•  The need for regular, routine monitoring

The client with a known benign polyp that does not need to be removed has frequent sigmoidoscopic or colonoscopic examinations to monitor for any growth or change in the polyp or for an increase in the number of polyps. If the client has undergone a polypectomy, follow-up sigmoidoscopic or colonoscopic examinations are needed, because there is an in­creased risk of multiple polyps in the client who has had at least one polyp.

Nursing care of the client who has undergone a polypec­tomy of the colorectal area includes monitoring for abdomi­nal distention and pain, rectal bleeding, mucopurulent rectal drainage, and fever.

A small amount of blood might appear in the stool after a polypectomy, but this should be temporary. Nursing care of the client who has undergone a total colectomy is described in Chapter 58 under Crohn’s Disease.

HEMORRHOIDS

OVERVIEW

Hemorrhoids are unnaturally swollen or distended veins in the anorectal region. Hemorrhoids are common and not sig­nificant unless they cause pain or bleeding. The veins in­volved in the development of hemorrhoids are part of the normal structure in the anal region. With limited distention, the veins function as a valve overlying the anal sphincter that assists in continence. Increased intra-abdominal pres­sure causes elevated systemic and portal venous pressure, which is transmitted to the anorectal veins. Arterioles in the anorectal region shunt blood directly to the distended anorectal veins, which increases the pressure. With repeated elevations in pressure from increased intra-abdominal pres­sure and engorgement from arteriolar shunting of blood, the distended veins eventually separate from the smooth muscle surrounding them. The result is prolapse of the hemor-rhoidal vessels.

Hemorrhoids can be internal or external (Figure 57-8). In­ternal hemorrhoids, which cannot be seen on inspection of the perineal area, lie above the anal sphincter. External hemor­rhoids lie below the anal sphincter and can be seen on in­spection of the anal region. Prolapsed hemorrhoids can be­come thrombosed or inflamed, or they can bleed.

The most common causes of repeated increased abdominal pressure resulting in hemorrhoids are straining at stool, preg­nancy, portal hypertension, and colorectal cancer.

COLLABORATIVE MANAGEMENT

 Assessment

The most common symptoms of hemorrhoids are bleeding and prolapse. Blood is characteristically bright red and is present on toilet tissue or outside the stool. Pain is a common symptom and is often associated with thrombosis, especially if thrombo­sis occurs suddenly. Other symptoms include itching and a mu­cous discharge. Diagnosis is made by inspection, digital exam­ination, proctoscopy, or proctoscopic ultrasonography.

Interventions

Interventions are typically conservative and are aimed at re­ducing symptoms with a minimum of discomfort, cost, and time lost from usual activities.

NONSURGICAL MANAGEMENT. Local treatment and diet therapy are initiated when symptoms begin. Cold packs applied to the anorectal region for a few minutes at a time be­ginning with the onset of pain and hot sitz baths three or four times a day are often enough to relieve discomfort, even if the hemorrhoids are thrombosed.

Witch hazel soaks (e.g., Tucks) are also effective for pain. Topical anesthetics, such as lidocaine (Xylocaine), are useful for severe pain. Dibucaine (Nupercainal) ointment, an over-the-counter remedy, may be applied for mild to moderate pain. This ointment should be used only temporarily, how­ever, because it can mask worsening symptoms and delay di­agnosis of a severe disorder. 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 to 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 well as foods and beverages that can make hemorrhoids worse. Spicy foods, nuts, coffee, and alcohol can be irritating. Clients are encouraged to avoid sitting for long periods of time. The health care provider may prescribe oral analgesics for pain if the hemorrhoids are thrombosed.

Conservative treatment should alleviate symptoms in 3 to 5 days. If symptoms continue or recur frequently, the client may require surgical intervention.

SURGICAL MANAGEMENT. The surgeon can perform several procedures for symptomatic hemorrhoids. The type of surgery depends on the degree of prolapse, whether there is thrombosis, and the overall condition of the client. Surgical methods include sclerotherapy, elastic band ligation, cryosurgery, and hemorrhoidectomy.

In sclerotherapy, the surgeon injects a sclerosing agent into the tissues around the hemorrhoids to obliterate the ves­sels. Sclerotherapy can be done on an outpatient basis without long-term pain. However, it can be done only for low-grade hemorrhoids.

Elastic band ligation is considered a better method be­cause of its success rate. One or two rubber bands are put on at one ambulatory care visit, and repeated visits may be needed for ligation of all hemorrhoids. Local pain after liga­tion does occur, and hemorrhage may also occur.

Cryosurgery, which can be done on an ambulatory care basis, involves freezing the hemorrhoid with a probe to cause necrosis. Because of its many disadvantages (e.g., profuse and foul drainage lasting up to 6 weeks; hemorrhage; large, painful skin tags; and incomplete destruction), cryosurgery is no longer a widely accepted method.

Hemorrhoidectomy, the standard treatment, caow be performed in an ambulatory care/same-day surgical setting. Approximately 10% of clients with symptomatic hemorrhoids undergo hemorrhoidectomies. The most common problem fol­lowing a hemorrhoidectomy is pain, which is severe for 1 to 2 days after surgery. Urinary retention can also occur because of rectal spasms and anorectal tenderness. Hemorrhage, which may be internal and not visible or external, is a rare but poten­tial complication.

The nurse teaches clients with hemorrhoids about the need for adhering to high-fiber, high-fluid diets to promote regular bowel patterns. The nurse advises clients to avoid stimulant laxatives, which are habit forming.

For clients who undergo any type of surgical intervention, the nurse monitors for hemorrhage and pain postoperatively. These clients, in particular, require ongoing interventions for pain because of its severity. Appropriate nursing interventions include the following:

•  Assisting clients to a side-lying position

•  Keeping fresh ice packs over the dressing until the pack­ing is removed

•  Use of moist heat (as in sitz baths) three or four times a day after the first 12 hours postoperatively

Vasodilation from the sitz bath redirects blood to the rectal area, which might cause the client to feel faint. The nurse may place an ice bag on the client’s head during the sitz bath to prevent feelings of faintness. A flotation pad can be used un­der the buttocks for sitting. The first postoperative bowel movement may be very painful. The physician usually prescribes stool softeners, such as docusate sodium, to begin on the first postoperative day.
Opioid analgesics are administered before the client attempts to defecate, and the caregiver should stay nearby during the first defecation. All clients who have undergone a hemor­rhoidectomy are monitored for urinary retention.

MALABSORPTION  SYNDROME    

OVERVIEW

Malabsorption is a syndrome associated with a variety of disorders and intestinal surgical procedures. Malabsorption 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 the following 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.

Enzymes normally found in the intestine split disaccha-rides (complex sugars) to monosaccharides (simple sugars). Examples of these enzymes are lactase, sucrase, maltase, and isomaltase. Lactase deficiency is the most common disaccha-ride enzyme deficiency. Without sufficient amounts of this enzyme, the body is not able to break down lactose. Lactase deficiency can be due to genetic transmission, injury to intes­tinal mucosa from viral hepatitis, bacterial proliferation in the intestine, or sprue. 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, these nutrients are malab-sorbed. 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 there is a decrease in peri­stalsis. Bacteria at these sites break down bile salts, and fewer salts are available for fat absorption. These bacteria can also ingest vitamin B₁₂, which contributes to vitamin B₁₂ defi­ciency. This phenomenon can occur after a gastrectomy or with progressive systemic sclerosis and diabetic enteropathy.

Disruption of the mucosal lining of the intestine is responsi­ble for the malabsorption that occurs with celiac (nontropical) sprue, tropical sprue, Crohn’s disease, and ulcerative colitis.

In celiac (nontropical) sprue, the absorptive surface area in the small intestine is lost; there is malabsorption of most nu­trients. Celiac sprue is thought to be due to a genetic immune hypersensitivity response to gluten or its breakdown products or to result from the accumulation of gluten in the diet with peptidase deficiency.

Tropical sprue is caused by an infectious agent that has not been identified but is thought to be bacterial. Mucosal changes occur in a more widespread manner than in celiac sprue. However, the changes are not as severe as in celiac sprue. Tropical sprue results in malabsorption of fat, folic acid, and vitamin B₁₂ in later stages of the disease.

The inflammation in Crohn’s disease interferes with the surface of cells absorbing bile salts and therefore leads to fat malabsorption. In ulcerative colitis, protein loss may occur.

Obstruction to lymphatic flow in the intestine can lead to loss of plasma proteins along with loss of minerals (such as iron, copper, and calcium), vitamin B₁₂, folic acid, and lipids. Lymphatic obstruction can be caused by many conditions. Certain cancers, such as lymphoma, inflammatory states, ra­diation enteritis, Crohn’s disease, Whipple’s disease, conges­tive heart failure, and constrictive pericarditis, are causes of lymphatic obstruction.

Interference with blood flow to the intestinal mucosa, which occurs in celiac and superior mesenteric artery disease, 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. Other conditions associated with maldigestion and malabsorption include small-bowel ischemia and radiation enteritis.

 COLLABORATIVE MANAGEMENT

 Assessment

Diarrhea is the classic symptom of malabsorption. It occurs secondary to unabsorbed nutrients, which add to the bulk of the stool, and unabsorbed fat. Steatorrhea (greater thaormal amounts of fat in the feces) is a common sign. Steatorrhea is a result of bile salt deconjugation, nonabsorbed fats, or bacteria in the intestine. Not all clients with malabsorption will have di­arrhea; instead, many clients manifest an increased stool mass. Other clinical manifestations include the following:

•  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)

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 loss occurs. A quantitative fecal fat analysis is elevated in either malabsorption or maldigestion.

A lactose tolerance test result that shows less than a 20% rise in the blood glucose level over the fasting blood glucose level indicates lactose intolerance. A monosaccharide test val­idates or rules out lactase deficiency. The xylose absorption test can reveal low urine and serum D-xylose levels if malab­sorption in the small intestine is present, a common finding in celiac sprue. An abnormal D-xylose test can indicate bacter­ial overgrowth in the small intestine.

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 client has bacterial over­growth, the bile salts will become deconjugated, and the car­bon dioxide level in the breath will peak earlier than expected.

Biopsy of the small intestine is performed via an oral endo-scopic procedure for diagnosis of tropical sprue or celiac sprue. Ultrasonography is used to diagnose pancreatic tumors and tumors in the small intestine that are causing malabsorp­tion. X-ray studies of the gastrointestinal (GI) tract reveal pan­creatic calcifications, tumors, or other abnormalities that cause malabsorption. Barium enema examination shows mucosal changes representative of celiac sprue or other abnormalities.

Interventions

Interventions for most malabsorption syndromes focus on avoidance of dietary substances that aggravate malabsorption and supplementation of nutrients. Surgical or nonsurgical management of the primary disease may be indicated. Drug therapy may also improve or resolve malabsorption.

Dietary management includes a low-fat diet for clients who have gallbladder disease, severe steatorrhea, cystic fibro-sis, and progressive systemic sclerosis. 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 client because it has a high amount 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 for clients with lactase defi­ciency, and gluten-free diets are available for clients with celiac sprue.

The physician orders nutritional supplements according to the specific deficiency. Common supplements include the following:

•  Water-soluble vitamins, such as folic acid, vitamin B₁₂, 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 tropical sprue, Whipple’s dis­ease, and other disorders involving bacterial overgrowth. Tropical sprue is treated with trimethoprim/sulfamethoxazole (Bactrim, Septra). Bacterial overgrowth can be caused by a variety of disorders but is often treated with tetracycline and metronidazole (Flagyl, Novonidazol¹*). Steroids are some­times given in celiac disease to decrease inflammation.

Drug therapy is used to control the clinical manifestations of malabsorption. Antidiarrheal agents, such as diphenoxylate hydrochloride and atropine sulfate (Lomotil) or kaolin with pectin (Kaopectate, Kao-Con), are often used to control diar rhea and steatorrhea (see Chart 57-1). Anticholinergics, such as dicyclomine hydrochloride (Bentyl, Bentylol’*’), ^are often given before meals to inhibit gastric motility. IV fluids may be necessary to replenish fluid losses associated with diarrhea.

BEST PRACTICE/or

Special Skin Care for Clients with Chronic Diarrhea

Use medicated wipes or premoistened disposable wipes

rather than toilet tissue to clean the perineal area.

Clean the perineal area well with mild soap and warm

water after each stool; rinse soap from the area well.

If the physician allows, provide a sitz bath several times

a day.

Apply a thin coat of vitamin A & D ointment or other

medicated protective covering, such as aloe products,

after each stool.

Keep the client off the affected buttock area.

For open areas, cover with thin DuoDerm or Tegaderm

occlusive dressing to promote rapid healing.

Observe for fungal or yeast infections, which appear as

dark red rashes. Obtain an order for medication if this

problem occurs.

The nurse provides special measures to protect the skin when diarrhea occurs (Chart 57-8). The nurse conducts an on­going assessment for clinical manifestations of malabsorption and relates these to activities and dietary intake. For example, clients with steatorrhea are monitored for fluid and electrolyte imbalances and are encouraged to ingest electrolyte-rich liq­uids liberally. The nurse teaches clients the rationale for di­etary, drug, and surgical management of nutritional deficien­cies and evaluates interventions on the basis of changes in or resolution of clinical manifestations.

Interventions for Clients with Inflammatory Intestinal Disorders

ACUTE INFLAMMATORY BOWEL DISORDERS

Appendicitis, peritonitis, and gastroenteritis are the most common acute inflammatory bowel problems. These disor­ders are potentially life threatening, and can have major sys­temic complications if not treated promptly.

Appendicitis

OVERVIEW

Appendicitis is acute inflammation of the vermiform appendix the blind pouch attached to the cecum of the colon that is usually located in the right iliac region, just below the ileocecal valve. The appendix has no known function. As part of the cecum, it fills with food and empties on a regular basis. Inflammation of the appendix can occur when the lumen (opening) of the appendix is obstructed. Inflammation leads to infection as bacteria invade the wall of the appendix.

When the lumen is blocked, the mucosa continues to se­crete fluid until the pressure within the lumen exceeds venous pressure. Blood flow to the appendix is restricted, and infection causes more swelling, which further impedes blood flow. Gangrene from hypoxia or perforation can occur within 24 to 36 hours. If this process occurs slowly, adjacent organs may wall off the area, and a localized abscess develops. If the in­fectious process occurs rapidly, peritonitis (inflammation of the peritoneum) may result. All complications of peritonitis are serious. Acute appendicitis is the most common cause of acute inflammation in the right lower quadrant. Consequently, it is one of the most common indications for emergency ab­dominal surgery.

When obstruction is present, calculi composed of fecal material (fecaliths), calcium phosphate-rich mucus, and inor­ganic salts may be the most common cause of the initial ob­struction. Other causes of obstruction include tumors, viral in­fections, and worms. However, recent evidence points to ulceration of the mucosa as the primary cause of appendicitis (Silen, 1998). Infection by viral or fungal pathogens has been suggested as the cause of ulceration. Although appendicitis affects a person at any age, the peak incidence is between the ages of 20 and 30 years. Appendicitis affects men and women equally, except before 25 years of age, when males are af­fected more often than females at a 3:2 ratio (Silen, 1998).

It is thought that chronic infection of the appendix can oc­cur, but this is not usually the cause of abdominal pain that lasts for weeks or months. Recurrent acute appendicitis does sometimes occur, often with complete remission of inflam­mation between acute attacks. In rare instances, acute appen­dicitis may be the first manifestation of Crohn’s disease.

CONSIDERATIONS FOR OLDER ADULTS

Appendicitis is relatively rare at extremes in age; how­ever, perforation is more common in older people, causing a higher mortality rate. The diagnosis of appendicitis is difficult to establish in older adults, as symptoms of pain and tender­ness are not as pronounced in this age-group. As a result, 30% of older clients with appendicitis develop perforation due to a delay in diagnosis. The development of peritonitis is as­sociated with a 15% mortality rate in older adults (Silen, 1998).

COLLABORATIVE MANAGEMENT

Assessment

The history obtained from the client outlining the sequence of events provides the most important assessment of appendici­tis. The most common symptom is abdominal pain, which re­sults from contractions of the appendix or distention of its lu­men. With classic appendicitis, abdominal pain in the epigastric or periumbilical area is the initial symptom. Pain may not be localized, however, and can exist anywhere in the abdomen or flanks. The pain at this time is described as mild or cramping. Nausea and vomiting follow in 50% to 60% of cases. As the inflammation spreads to the peritoneal surface, the pain becomes more steady and severe and the location shifts to the right lower quadrant. Abdominal pain that in­creases with cough or movement and is relieved by flexion of the right hip or the knees suggests a perforated appendix with peritonitis. Anorexia is a frequent finding associated with acute appendicitis.

Abdominal tenderness on palpation is the most common, important, and reliable symptom. In later stages of inflamma­tion, tenderness becomes more localized and is noted with palpation of the right lower quadrant. This area is referred to as McBurney’s point; it is located midway between the an­terior iliac crest and the umbilicus in the right lower quadrant

(Figure 58-1). The nurse may feel tenseness of the muscles (muscle rigidity) over the tender area. Rigidity over the whole abdomen, accompanied by tense positioning and guarding, in­dicates a perforated appendix with peritonitis. Perforation rarely occurs within 24 hours of the onset of symptoms, but the incidence of peritonitis rises to as high as 80% after 48 hours. Rebound tenderness is a term used to describe a sensa­tion of severe pain that occurs after deep pressure is applied and released. This maneuver involves pressing a finger into the abdomen at a point away from the pain and is performed by the physician or advanced-practice nurse.

The client’s temperature is usually normal or slightly ele­vated at 99° to 100.5° F (37.2° to 38° C). A temperature of 101° F (38.2° C) or higher suggests the presence of peritoni­tis. As the temperature rises, a corresponding rise in pulse rate will be noted.

Because the clinical manifestations associated with many other medical conditions are similar to those of acute appen­dicitis, arriving at a diagnosis is often difficult. It is important for the nurse to determine the sequence of symptoms. For ex­ample, nausea and vomiting that precede abdominal pain of­ten indicate gastroenteritis.

Clinical manifestations that do not follow the classic pattern can occur as a result of variations in the anatomic location of the appendix. The appendix can be located deep in the pelvis, in the right upper quadrant, or even in the left lower quadrant.

Laboratory findings do not establish the diagnosis, but there is often a moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000/mm³ with a “shift to the left” (an increased number of immature WBCs). A WBC elevation greater than 20,000/mm³ may indicate a perforated appendix. An ultrasound study may show the pres­ence of an enlarged appendix. If symptoms are recurrent or prolonged, a barium enema or computed tomography (CT) scan may reveal the presence of a fecalith.

■» Interventions

All clients with suspected or confirmed appendicitis are hos­pitalized and examined by a surgeon. If the diagnosis is ques­tionable, the health care team observes the client before sur­gical exploration.

 

   NONSURGICAL MANAGEMENT. After admission to the hospital, the physician keeps the client with suspected or known appendicitis oothing by mouth (NPO) status to pre­pare for the possibility of emergency surgery and to avoid ag­gravating the inflammatory process. The nurse administers in­travenous (IV) fluids, as ordered, to prevent fluid and electrolyte imbalance and to replenish fluid volume. If the semi-Fowler’s position can be tolerated, the nurse advises the client to maintain this position so that abdominal drainage, if any, can be contained in the lower abdomen.

Once the diagnosis of appendicitis is confirmed, the sur­geon schedules surgery. The nurse may administer opioid analgesics, as ordered, while the client is being prepared for surgery. The client with suspected appendicitis should not receive laxatives or enemas, which can cause perforation of the appendix. Heat should never be applied to the abdomen be­cause this may increase circulation to the appendix and result in increased inflammation and perforation.

SURGICAL MANAGEMENT. Surgery is required as soon as possible. If the diagnosis is not definitive but the client is at high risk for complications from suspected appendicitis, the surgeon may perform an exploratory laparotomy to rule out appendicitis.

PREOPERATIVE CARE. Preoperative teaching is often limited because the client is in pain or may be transferred to the operating suite for emergency surgery. The nurse prepares the client for general anesthesia and surgery (see Chapter 17).

OPERATIVE PROCEDURES. An appendectomy is the removal of the inflamed appendix. In a traditional, uncompli­cated appendectomy, the surgeon removes the appendix through an incision approximately 3 inches (7.5 cm) long in the right lower quadrant. The incision is larger if the appendix is in an atypical position or if peritonitis is present.

An appendectomy is often done via laparoscopy. The surgeon makes several small incisions through which an endo-scope is inserted. A cutting instrument is threaded through the endoscope, and the appendix is removed.

POSTOPERATIVE CARE. Postoperative care of the client who has undergone an appendectomy includes the care re­quired for any client who has received general anesthesia (see Chapter 19). For clients who have undergone a traditional ap­pendectomy, the incision is located over McBurney’s point if the appendix was in the typical location. The incision may be as long as the length of the abdomen, depending on the area explored in surgery and the location of the appendix. Drains may have been inserted during the procedure if an abscess was present or if the appendix perforated. The drains are left in place for several days.

If peritonitis was present, a nasogastric (NG) tube is placed to decompress the stomach and prevent abdominal distention. IV antibiotics are typically prescribed if peritonitis or abscess is present. Opioid analgesics are administered for pain as needed. The client is typically out of bed on the evening of surgery or the first postoperative day. The client who has had an uncomplicated appendectomy via laparoscopy may stay overnight or may be discharged on the day of surgery. In this case, no NG tubes or drains are needed.

The client who has undergone an uncomplicated appen­dectomy usually recovers rapidly. After a traditional surgical procedure, he or she can resume normal activity in 2 to 4 weeks. If surgery has been complicated by perforation or peri­tonitis, he or she is hospitalized for 5 to 7 days or longer.

If the client is discharged to a home setting, the nurse as­sesses his or her ability to function with the added tasks of in­cision care, drug therapy, and some activity restrictions. The nurse assesses the home environment and the need for support to meet physical needs.

Peritonitis

OVERVIEW

Peritonitis is an acute inflammation of the endothelial lining of the abdominal cavity, or peritoneum. Peritonitis can be classified as primary or secondary, localized or generalized. Peritonitis is a life-threatening illness and is associated with several abdominal disorders.

Pathophysiology

 PATHOLOGIC CHANGES

Normally, the peritoneal cavity contains approximately 50 mL of sterile fluid (transudate), which serves to prevent friction in the abdominal cavity during peristalsis (Hirsch & Caswell, 1999). When the peritoneal cavity is contaminated by bacteria, the body initially produces an inflammatory re­action that walls off a localized area to fight the infection. This local reaction involves vascular dilation and increased capillary permeability, allowing for transport of leukocytes and subsequent phagocytosis of the offending organisms. If this walling off process fails, the inflammation spreads and contamination becomes massive, resulting in diffuse peri­tonitis.

COMPLICATIONS

Vascular dilation continues, along with hyperemia (increased blood flow) and a fluid shift. The body responds to the infec­tious process by shunting extra blood to the area of inflam­mation. Fluid is shifted from the extracellular fluid (ECF) compartment into the peritoneal cavity, connective tissues, and gastrointestinal (GI) tract (“third spacing”). This shift of fluid out of the vascular space can result in a significant de­crease in circulatory volume. The rate of decreasing circula­tory volume is proportional to the degree of peritoneal in­volvement. Severely decreased circulatory volume can result in insufficient perfusion of the kidneys, leading to renal fail­ure with electrolyte imbalance.

Peristalsis slows or stops in response to severe peritoneal infection, and the lumen of the bowel becomes distended with gas and fluid. Fluid that normally flows to the small bowel and the colon for reabsorption accumulates in the intestine in volumes of 7 to 8 L daily. The toxins or bacteria responsible for the peritonitis can also enter the bloodstream from the peritoneal area, leading to bacteremia or septicemia (bacterial invasion of the blood).

Respiratory problems can occur as a result of increased ab­dominal pressure against the diaphragm from intestinal dis­tention and fluid shifts to the peritoneal cavity. Pain can interfere with ventilatory efforts when the client has an in­creased oxygen demand because of the infectious process.

 TYPES OF PERITONITIS

Primary peritonitis is an acute bacterial infection that devel­ops as a result of contamination of the peritoneum through the vascular system. Tuberculous peritonitis that arises from a tu­berculin infection originating elsewhere in the body is a type of primary peritonitis. Clients with alcoholic cirrhosis and as-cites, in the absence of a perforated organ, often manifest peritonitis, which may be due to leakage of bacteria through the wall of the intestine.

Secondary peritonitis is usually caused by bacterial inva­sion as a result of an acute abdominal disorder. Secondary peritonitis can develop as a result of a gangrenous bowel, per­foration of the viscera by blunt or penetrating trauma, or bile leakage.

 Etiology

Peritonitis is caused by contamination of the peritoneal cavity by bacteria or chemicals. Bacteria gain entry into the peri­toneum by perforation or from an external penetrating wound. The most common causes of bacterial peritonitis are appen­dicitis and perforations associated with peptic ulcer disease, diverticulitis, a gangrenous gallbladder, or bowel obstruction. Bacterial invasion can also occur from an ascending infection through the reproductive tract, as in salpingitis or a septic abortion. Other causes of peritonitis include perforating tu­mors, ulcerative colitis, foreign bodies (from trauma), leakage or contamination during a surgical procedure, and infection by skin pathogens in clients undergoing continuous ambulatory peritoneal dialysis (CAPD). Bacteria responsible for peritoni­tis include Escherichia coli, Streptococcus, Staphylococcus, Pneumococcus, and Gonococcus. Chemical peritonitis arises from leakage of bile, pancreatic enzymes, and gastric acid.

 Incidence/Prevalence

Primary peritonitis accounts for only a small percentage of the cases of peritonitis. The incidence of secondary peritoni­tis is difficult to determine because data usually relate to the underlying cause, such as appendicitis or peptic ulcer.

 

COLLABORATIVE MANAGEMENT

 Assessment

 HISTORY

The nurse questions the client regarding a history of abdomi­nal pain and determines if the pain is localized or generalized. The nurse also asks about a history of a low-grade fever or re­cent spikes in temperature.

 PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

Physical findings of peritonitis (Chart 58-1) depend on sev­eral factors: the stage of the disease, the ability of the body to localize the process by walling off the infection, and whether the inflammation has progressed to generalized peritonitis. The client typically appears acutely ill, lying still, possibly with the knees flexed. Movement is guarded, and the client may report and show signs of pain (e.g., facial grimacing) with coughing or movement of any type. During inspection, the nurse may observe progressive abdominal distention if the inflammation markedly reduces intestinal motility. The nurse may auscultate for bowel sounds, but these usually disappear with progression of the inflammation.

The cardinal signs of peritonitis are abdominal pain and tenderness. In the client with localized peritonitis, the ab­domen is tender on palpation in a well-defined area of the ab­domen with rebound tenderness in this area. With generalized peritonitis, tenderness is widespread. Abdominal wall rigidity is a common finding. The client may have a high fever be­cause of the infectious process, with tachycardia occurring in response to the fever. The nurse assesses whether the client has dry mucous membranes with poor tissue turgor and a low urine output. A low urine output occurs because fluid accu­mulates in the peritoneal cavity, the GI tract, and connective tissues, resulting in a fluid deficit in the vascular space. Nau­sea and vomiting may also be present. Hiccups may occur as a result of diaphragmatic irritation. Depending on the severity of the peritonitis, the nurse may find that the client has a com­promised respiratory status.

 DIAGNOSTIC ASSESSMENT

White blood cell (WBC) counts are commonly elevated to 20,000/mm³ with a high neutrophil count. A series of blood culture studies may be done to determine whether septicemia has occurred and to identify the causative organism to enable appropriate therapy.

The health care provider orders laboratory tests to assess fluid and electrolyte balance and renal status, including the following:

•  Electrolytes

•  Blood urea nitrogen (BUN)

•  Creatinine

•  Hemoglobin

•  Hematocrit

Arterial blood gas values are obtained to assess respiratory function and acid-base balance.

 

Abdominal x-ray films are obtained to assess for free air or fluid in the abdominal cavity, which indicates perforation. The x-ray films may also show dilation, edema, and inflam­mation of the small and large intestines.

The physician may perform a diagnostic peritoneal lavage by instilling 1 L of fluid through a peritoneal dialysis catheter. Lavage fluid positive for peritonitis is characterized by the following: more than 500 WBCs/mL³ of fluid, more than 50,000 red blood cells (RBCs)/mL, or the presence of bacte­ria on a Gram stain. Bile-stained green fluid may indicate a ruptured gallbladder or perforated intestine, which can lead to chemical peritonitis.

 Interventions

All clients with peritonitis are hospitalized because of the se­vere nature of the illness. If complications are extensive, the client may be admitted to a critical care unit. Nursing inter­ventions focus on the early identification of complications.

NONSURGICAL MANAGEMENT. The physician pre­scribes IV fluids and broad-spectrum antibiotics immediately after establishing the diagnosis of peritonitis. IV fluids are necessary to replace fluids collected in the peritoneum and bowel. Daily weight and intake and output are monitored to assess fluid status. A nasogastric (NG) tube is inserted to de­compress the stomach and the intestine, and the client is on NPO status. The nurse administers oxygen, as ordered, ac­cording to the client’s respiratory status. The health care provider will most likely institute pain management with IV analgesics, such as morphine sulfate administered via a pa­tient-controlled analgesia (PCA) pump. Even with nonsurgi-cal management of peritonitis, the nurse can expect the health care provider to order a surgical consultation in the event that surgery becomes necessary.

SURGICAL MANAGEMENT. Abdominal surgery is the optimal treatment for identifying and repairing the cause of the peritonitis. If the client is so critically ill that surgery would be life threatening, it may be delayed. Surgery focuses on controlling the contamination, removing foreign material from the peritoneal cavity, and draining collected fluid.

The surgeon performs an exploratory laparotomy to re­move or repair the inflamed or perforated organ. The abdom­inal cavity is opened surgically and explored for inflamed and perforated organs or other abnormalities.

PREOPERATIVE CARE. The preoperative care for the client undergoing an exploratory laparotomy is similar to that described in Chapter 17 for the client receiving general anesthesia.

OPERATIVE PROCEDURES. For an exploratory laparo­tomy, the surgeon makes an incision through the abdominal wall and explores the abdominal cavity. Part or all of a per­forated or inflamed organ may be removed, depending on that organ’s function. For example, an appendectomy is per­formed for an inflamed appendix; a colon resection, with or without a colostomy, is indicated for a perforated diverticu-lum or perforated colon secondary to a tumor. Before the ab­dominal cavity is closed, the surgeon irrigates the peritoneum with antibiotic solutions. Two to four catheters may also be inserted to drain the cavity and provide a route for irrigation postoperatively.

POSTOPERATIVE CARE. Postoperative care is similar to that for other clients undergoing surgery (see Chapter 19). Clients with peritonitis may have actual or potential multisys­tem complications. Therefore the nurse initially monitors level of consciousness, vital signs, respiratory status (respira­tory rate and breath sounds), and fluid and electrolyte status (intake and output and laboratory values) at least hourly.

Positioning. The nurse maintains the client in a semi-Fowler’s position to promote drainage of peritoneal contents in the inferior region of the abdominal cavity. This position also facilitates adequate respiratory excursion in that the di­aphragm and abdominal contents are impinging on respira­tory muscles.

Wound Care. The client is likely to have multiple inci­sions and drains. Because contamination at the time of sur­gery impedes healing of an incision with edges well approxi­mated (by first intention), incisions are allowed to heal by second or third intention. These incisions necessitate meticu­lous care involving manual irrigation or packing, as ordered by the surgeon. If the surgeon orders peritoneal irrigation through a drain, the nurse maintains sterile technique during manual irrigation, usually by using a catheter-tipped syringe. The nurse determines that the client is not retaining irrigant by ensuring the absence of abdominal distention or pain and by monitoring irrigant intake and output.

As a result of the loss of fluids from the extracellular space to the peritoneal cavity, IV fluid replacement and maintenance are indicated for all clients with peritonitis. Fluid volume deficit also occurs as a result of nasogastric suctioning and NPO status. Normal saline or a balanced saline solution with potassium is administered intravenously according to electrolyte, BUN, and serum creatinine values. To assess fluid volume, the nurse mon­itors the client’s vital signs, urine output, skin turgor, integrity of mucous membranes, and most important, weight. The nurse also assesses for edema from third spacing.

CONSIDERATIONS FOR OLDER ADULTS

BaOThe older adult often does not have characteristic signs and symptoms of dehydration. A change in mental status may be an early sign of fluid deficit. The nurse assesses skin turgor on an older client using the skin over the forehead or sternum. The nurse provides frequent mouth care to help maintain moist mucous membranes. The use of lemon-glycerin swabs is avoided because they can increase dryness.

 Community-Based Care

The length of hospitalization depends on the extent and sever­ity of the infectious process. Clients who have a localized ab­scess drained and who respond to antibiotics and IV fluids without respiratory, renal, or cardiac complications are dis­charged in about a week. Clients who experience complica­tions of peritonitis, along with sepsis or shock, may require mechanical ventilation or hemodialysis, with hospital stays lasting for several weeks. Discharge planning varies with the degree of involvement of all body systems. Some clients may be transferred to a subacute unit to complete their antibiotic therapy and recovery. If the client is being discharged to home, the nurse assesses his or her ability to function at home with the added task of incision care and a diminished activity tolerance. The nurse provides the client with written and oral instructions to report the following:

·        Unusual or foul-smelling drainage

·        Swelling, redness, or warmth or bleeding from the inci­sion site

·        A temperature higher than 101° F (38.2° C)

·        The presence of abdominal pain

The nurse also instructs the client in proper handwashing and dressing change techniques, which include directions to dress wounds separately to avoid cross-contamination.

The physician prescribes an oral opioid analgesic and pos­sibly an antibiotic. The nurse reviews information about these medications with the client and caregiver. For clients taking opioid analgesics for any length of time, a stool softener should be prescribed.

The nurse also explains diet and activity limitations. Diet depends on the type of surgery performed and the client’s spe­cific food tolerances at the time of discharge. All clients are told to refrain from any lifting for at least 6 weeks. Other ac­tivity limitations are made on an individual basis with the physician’s recommendation.

Peritonitis is a life-threatening and consequently frighten­ing illness. Incisional care can be demanding, and activity in­tolerance can be overwhelming. If complications have re­solved, the nurse reassures clients that they can realistically expect to resume their previous lifestyle. Convalescence is of­ten longer than that required for other types of surgery, how­ever, because of the multisystemic involvement.

Clients with an incision healing by second or third inten­tion may require dressings, solution, and catheter-tipped sy­ringes to irrigate the wound. The nurse may arrange for a home care nurse to assess, irrigate, or pack the wound and change the dressing as needed. If a client needs assistance with activities of daily living, a home care aide or temporary placement in a skilled care facility may be indicated. The case manager collaborates with the health care team to determine the most appropriate setting for community-based care.

Gastroenteritis

OVERVIEW

Acute diarrheal illnesses cause significant morbidity among young children and adults, especially in less-developed na­tions of the world. Gastroenteritis is an increase in the fre­quency and water content of stools and/or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract. Gastroenteritis primarily affects the small bowel and can be of either viral or bacterial origin. Both forms have similar manifestations and are considered self-limiting in their course unless complications occur. All organ­isms that are implicated in gastroenteritis cause diarrhea; however, the organisms discussed in this section have distin­guishing characteristics.

Authors disagree on classification of the infectious dis­eases described as gastroenteritis. Some investigators include shigellosis when discussing gastroenteritis; others consider shigellosis separately as a dysentery type of illness. Dysen­teries affect the large bowel; gastroenteritis affects the small bowel. Other authors classify infectious disease of the intes­tine as bacterial, viral, or parasitic, without using the term gastroenteritis.

Food poisoning is sometimes described in conjunction with gastroenteritis, with specific reference to the organism causing the food poisoning. Gastroenteritis, however, differs from food poisoning with regard to transmission in the body, incubation time, and effect on immunity.

The following discussion of gastroenteritis includes the viral forms (epidemic viral, rotavirus) and the bacterial forms (Campylobacter, Escherichia coli, and shigellosis) (Table 58-1). Organisms associated with food poisoning and para­sitic infections are discussed under Food Poisoning, p. 1295.

Pathophysiology/Etiology

Infection with viral and bacterial organisms can produce gas­trointestinal (GI) illnesses in which watery diarrhea is the pri­mary feature. These disorders can be caused by noninflamma­tory, inflammatory, or penetrating mechanisms. The infecting organism (e.g., enterotoxigenic E. coli) can release enterotoxin (a noninflammatory toxic substance specific to the intestinal mucosa), which results in diarrhea. The organism (e.g., Shigella or Campylobacter) can also attach itself to mucosal epithelium without penetrating it. Cells of the intestinal villi are then destroyed, and malabsorption results. Infections that are mediated by bacterial toxins cause the absorptive capacity of the distal small bowel and proximal colon to be overcome, resulting in diarrhea. Finally, the organism (e.g., rotavirus) can penetrate the intestine, causing cellular destruction, necrosis, and a potential for ulceration. Diarrhea occurs often with white blood cells (WBCs) or red blood cells (RBCs) present in the stool.

All of these situations result in increased GI motility, with fluids and electrolytes being secreted into the intestine at rapid rates. Invading organisms have increased capabilities of attaching to the intestinal mucosa if the normal intestinal flora is altered. This can occur in clients who are receiving antibi­otics, are malnourished, or are debilitated. Two groups of viruses, the rotaviruses and Norwalk virus, as well as bacter­ial pathogens, are primary etiologic agents involved in the de­velopment of gastroenteritis.

 TYPES OF GASTROENTERITIS

VIRAL GASTROENTERITIS. Many types of ro­taviruses cause rotavirus gastroenteritis. The reservoir of these viruses is in humans. The viruses are transmitted via the fecal-oral route and possibly via the respiratory tract. Incuba­tion is 48 hours. The period of communicability is during the acute stage and shortly after. Rotavirus infection is generally limited to infants and young children; by age 2 years, most children have acquired antibodies against most types of these viruses.

Norwalk virus infection can occur year-round and affects adults and children alike. This virus is spread by the oral-fe­cal route and is responsible for one third of all epidemics of viral gastroenteritis in developed countries. The virus is also a common cause of waterborne epidemics of gastroenteritis.

BACTERIAL GASTROENTERITIS. There are three general types of bacterial gastroenteritis:

·        E. coli diarrhea (“traveler’s diarrhea”)

·        Campylobacter enteritis (“traveler’s diarrhea”)

·        Shigellosis (bacillary dysentery)

E. coli is the most common organism implicated in trav­eler’s diarrhea. The reservoirs of E. coli are humans, who are often asymptomatic. The organism is transmitted through fe-cally contaminated food, water, or fomites (any other sub­stance that transmits infection).

The etiologic feature of Campylobacter enteritis is the bac­terium Campylobacter jejuni; reservoirs are domestic or wild animals and birds. C. jejuni is transmitted through the fecal-oral route by ingestion of water or food contaminated with fe-ces or by direct contact with infected animals or infants. In­cubation ranges from 1 to 10 days. The organism is communicable for several days to weeks throughout the course of the infection (usually 2 to 7 weeks).

Shigellosis is caused by infection with Shigella bacteria. Direct or indirect fecal-oral transmission can occur from an infected person or carrier. The incubation period before the illness is 1 to 7 days. The illness can be communicated during the acute phase and for up to 4 weeks after the onset of the illness. A person may be a carrier of this illness for months af­ter the acute illness.

IIncidence/Prevalence

Acute GI illnesses are the second most common disease worldwide. Acute diarrheal illnesses are the most common cause of morbidity and mortality among children and older adults in Asia, Africa, and Latin America. Gastroenteritis of­ten occurs in epidemic outbreaks among groups of people.

Campylobacter enteritis occurs worldwide, commonly in epidemic outbreaks. Its incidence is highest during warm months. Diarrhea caused by E. coli also occurs worldwide, commonly in epidemics. The highest incidence is in areas of poor sanitation during warm months. Shigellosis occurs worldwide in every age-group but is most frequent in children under the age of 10 years. Children and older adults are more susceptible to Shigella because of their immature or de­pressed immune systems. Outbreaks of shigellosis are com­mon in areas with crowded living conditions.

COLLABORATIVE MANAGEMENT

 Assessment

The history elicited from the client can provide information related to the potential cause of the illness. The nurse ques­tions the client regarding a recent history of travel, especially to tropical regions of Asia, Africa, or Central or South Amer­ica. Traveler’s diarrhea can begin 3 days to 2 weeks following the client’s arrival.

The client who has gastroenteritis usually appears ill. Nausea and vomiting can occur with all types of gastroen­teritis but are usually limited to the first 1 or 2 days of the ill­ness. All clients with gastroenteritis classically have diarrhea, which varies in consistency and amount with the causative organism.

In clients with epidemic viral gastroenteritis, myalgia (muscle aches), headache, and malaise are often reported. The nurse notes slight abdominal distention. The nurse auscultates hyperactive bowel sounds and finds diffuse tenderness on pal­pation. However, there should be no rebound tenderness, which might indicate peritonitis. Depending on the amount of fluids lost through diarrhea and vomiting, the client may have varying degrees of dehydration manifested by the following:

•  Poor skin turgor

•  Dry mucous membranes

•  Orthostatic blood pressure changes

•  Hypotension

•  Oliguria

In some cases, dehydration may be severe, and shock may occur if diarrhea is prolonged. Dehydration occurs rapidly in older adults.

Diarrhea associated with epidemic viral gastroenteritis is typically limited to 24 to 48 hours. In rotavirus gastroenteri­tis, there is an elevated temperature and watery diarrhea last­ing 2 to 6 days. Mucus may be present in the stools of indi­viduals infected with rotavirus. Infection with the Norwalk virus is characterized by the rapid onset of nausea, abdominal cramps, vomiting, and diarrhea. The illness is usually mild, lasting 24 to 48 hours (Greenberg, 1998). Campylobacter en­teritis is a more severe disease with foul-smelling stools that contain blood and that caumber 20 to 30 per day for up to 7 days. E. coli gastroenteritis may or may not involve blood or mucus in the stool; diarrhea can last for up to 10 days. Shigella causes stools containing blood and mucus, which can continue for up to 5 days.

As part of the laboratory assessment, Gram stain of stool is usually done before culture. Many white blood cells (WBCs) on Gram stain suggest shigellosis. The presence of WBCs and red blood cells (RBCs) in the stool indicates Campylobacter gastroenteritis.

A stool culture that is positive for enterotoxigenic E. coli is diagnostic of E. coli diarrhea. Culture of stool that is posi­tive for Shigella when there are pus cells or WBCs present in the stool is diagnostic of shigellosis.

Sophisticated electron microscopy and immunoassay pro­cedures can identify epidemic viral gastroenteritis or rotavirus gastroenteritis; however, such examinations are rarely done because they are expensive and tedious to perform.

Interventions

For clients with most types of gastroenteritis, supportive treat­ment is instituted. Therapy is focused on fluid replacement, and the amount and route of fluid administration are deter­mined by fluid status.

FLUID REPLACEMENT. For mild cases of gastroenteri­tis, the client is treated on an ambulatory care basis or in the nursing home if he or she is a resident there. If the fluid vol­ume is severely depleted, the client is admitted to the hospital for administration of IV fluids. For older clients at home or in a long-term care setting, oral rehydration therapy (ORT) with commercially prepared rehydration products, such as Resol, may prevent hospitalization.

The nurse obtains weight, orthostatic blood pressure, and other vital sign measurements at the time of admission. Hy-potonic IV fluids, such as half-strength normal saline (0.45% sodium chloride), are infused as ordered. The nurse monitors the client’s vital signs, intake and output, and weight. A rapid gain or loss of 1 kg (2.2 pounds) of body weight is equivalent to the gain or loss of 1 L of fluid. Standard precautions are consistently observed when handling vomitus and stool.

The health care provider may order a potassium supple­ment to be added to IV fluids if the serum potassium level is low. To help assess renal function and prevent hyperkalemia, the nurse verifies that the client is voiding before and during potassium replacement. The client is advised to rest in bed, especially during periods of nausea or vomiting.

Depending on the type of gastroenteritis, the local health department may need to be notified. It is mandatory that every case of shigellosis be reported. In some endemic areas, Campylobacter enteritis needs to be reported on a case-by-case basis. Other types of gastroenteritis must be reported only if they occur in epidemic proportions. The nurse or case manager investigates state and local health department guide­lines for reporting requirements.

DIET THERAPY. Diet therapy is the same for the client who remains at home as for the client in the hospital. If the client is not actively vomiting, the nurse recommends small volumes of clear liquids with electrolytes (e.g., Gatorade) for 24 hours. The frequency and amount of oral intake can be in­creased if nausea and vomiting are not present. If nausea and vomiting continue, the nurse withholds food and fluids until these symptoms subside. The nurse advises the client not to drink water, because it does not contain any electrolytes to re­place those lost. After 24 hours, the diet for all clients can be advanced to include saltine crackers, toast, and jelly. When the client can tolerate this diet, bland foods (e.g., nonfat soup, custard, yogurt, cottage cheese, mashed or baked potatoes, and cooked vegetables) may be added. Caffeine is avoided, since it can increase intestinal motility. The client may progress to a regular diet as tolerated.

DRUG THERAPY. Drugs that suppress intestinal motility, such as anticholinergics and antiemetics, are not routinely given for bacterial or viral gastroenteritis. Use of these drugs can prevent the infecting organisms from being eliminated from the body. If the health care provider determines that an-tiperistaltic agents are necessary, an initial dose of loperamide 4 mg may be administered orally, followed by 2 mg after each loose stool, up to 16 mg/day. Bismuth subsalicylate (Pepto-Bismol) 30 mL or 2 tablets every 30 minutes for a maximum of 8 doses may be given to reduce the watery volume of the stool.

Treatment with antibiotics may be warranted if the gas­troenteritis is due to bacterial infection with fever and severe diarrhea. The health care provider may order norfloxacin (Chi-broxin, Noroxin) 400 mg twice a day PO or ciprofloxacin (Cipro) 500 mg twice a day PO for 3 days. If the gastroenteri­tis is due to shigellosis, anti-infective agents, such as trimetho-prim/sulfamethoxazole (Septra, Bactrim), are administered.

For relatively short-term diarrhea of 24 to 48 hours’ dura­tion, the diagnosis is based primarily on the client’s history and clinical manifestations without validation by a stool ex­amination. When diarrhea is severe or persists for long peri­ods, the stool is examined in an effort to determine the causative organism and to begin specific treatment. It should be determined if the diarrhea is caused by Salmonella or par­asites, because these organisms respond to specific medica­tions (see Parasitic Infection, p. 1292). Diarrhea that contin­ues longer than 10 days is probably not due to gastroenteritis, and a thorough investigation for the cause is warranted.

SKIN CARE. Frequent stools that are rich in electrolytes and enzymes, as well as frequent wiping and washing of the anal region, can irritate the skin. The nurse teaches the client to avoid toilet paper and harsh soaps. Ideally, the client can gently clean the area with warm water or absorbent cotton, followed by thorough drying with absorbent cotton. Cream, oil, or gel can be applied to a damp, warm washcloth to re­move excrement adhering to excoriated skin. Hydrocortisone cream or protective barrier cream should be applied to the skin between stools. Witch hazel compresses (e.g., Tucks) and sitz baths for 10 minutes, two to three times daily, can also re­lieve discomfort.

If leakage of stool is a problem, the client can put ab­sorbent cottoext to the anal orifice and keep it in place with snug underwear. For clients who are incontinent, the nurse keeps the perineal and buttock areas clean and dry. The use of incontinent pads instead of briefs allows air to circulate to the skin and prevents irritation.

HEALTH TEACHING. During the acute phase of the ill­ness, the nurse teaches about the importance of fluid replacemerit measures. The nurse teaches the client to follow the diet described earlier under Diet Therapy, p. 1273, and about any necessary medications. The nurse also teaches the client and family about the importance of minimizing the risk of trans­mission of gastroenteritis. Clients are advised to:

·        Wash their hands meticulously with an antibacterial soap, especially after bowel movements, and maintain good personal hygiene

·        Restrict the use of glasses, dishes, eating utensils, and tubes of toothpaste to themselves only

·        Maintain clean bathroom facilities to avoid exposure to stool

·        Inform the health care provider if symptoms persist be­yond 3 days

Clients adhere to these precautions for up to 7 weeks after the illness or up to several months if Shigella was the offend­ing organism. If the client is employed as a food handler, the public health department should be consulted for recommen­dations about the return to work (Chart 58-2).

CHRONIC INFLAMMATORY BOWEL DISEASE

Chronic inflammatory bowel disease (chronic IBD) refers to several inflammatory disorders of the gastrointestinal (GI) tract with no known etiology. Chronic IBDs may be divided into two major groups: ulcerative colitis and Crohn’s disease (Table 58-2).

Ulcerative Colitis

OVERVIEW

Ulcerative colitis is a chronic inflammatory process affecting the mucosal lining of the colon or rectum. This chronic in­flammatory process can result in loose stools containing blood and mucus, poor absorption of vital nutrients, and thickening of the colon wall. Over time, the client experiences episodes of abdominal discomfort and extraintestinal mani­festations of the disease that cause disruption of lifestyle. The affected client may have only minor periodic health problems, necessitating only ambulatory care, or serious problems, such as malnutrition and physical debilitation, requiring multiple hospitalizations.

Pathophysiology

Ulcerative colitis is characterized by diffuse inflammation of the intestinal mucosa; the result is a loss of surface epithelium with ulceration and possibly abscess formation. Generally, the disease begins in the rectum and proceeds in a uniform, con­tinuous manner proximally toward the cecum. The inflamma­tory process progresses to epithelial cell damage and loss, leaving areas of ulceration. The colon appears ulcerated, red­dened, and hemorrhagic. Ulcerative colitis is characterized by periods of remission and exacerbation.

Clients with acute ulcerative colitis may have vascular congestion, hemorrhage, edema, and ulceration of the bowel mucosa. As the disease course progresses, chronic changes in the colon occur. Fibrosis and retraction of the bowel result in muscle hypertrophy, deposition of fat and fibrous tissue, and a narrower and shorter colon. With long-term disease, dys-plastic changes to the surface epithelium occur. These changes are associated with an increased risk of colon cancer.

Complications of ulcerative colitis include the following:

·        Intestinal perforation with resultant peritonitis and fis­tula formation

·        Toxic megacolon

·        Hemorrhage

·        Increased risk of colon cancer
Abscess formation
Malabsorption

·        Bowel obstruction

·        Extraintestinal clinical manifestations, such as arthritis

Table 58-3 describes these common complications.

Etiology

The exact cause of ulcerative colitis is unknown. A genetic basis of the disease has been proposed because of the in­creased incidence seen in families, certain ethnic groups, and twins. Immunologic theories, including autoimmune dys­function, have been explored because of the extraintestinal manifestations of the disease. One hypothesis suggests that IBD results from an abnormal response to normal flora pres­ent in the intestines; another possibility is that there may be a defect in intestinal permeability that permits antigens to leak through the mucosa, stimulating an inflammatory re­sponse. Psychologic factors have also been implicated, since stress often results in a flare-up of the disease. However, there is little evidence to relate psychologic factors to the cause of the disease.

Incidence/Prevalence

There is a higher geographic distribution of the disease in northern Europe and North America. The annual incidence of ulcerative colitis is approximately 2 to 10 new cases per 100,000 persons. The prevalence is 40 to 100 cases per 100,000 people in the United States. There is a tenfold risk of the disease if an individual has a first-degree relative with the disease.

Peak incidence is between the ages of 15 and 25 years, with another peak occurring between ages of 55 and 65 years. Females are more often affected than men. Jewish Caucasians of European or Ashkenazic origin are at highest risk com­pared with other Caucasian groups (Rubin, 1998).

CULTURAL CONSIDERATIONS

^tUlcerative colitis is four to five times more common among people of Jewish origin and commonly affects Cau­casians in developed Western society. It is seen more often in individuals of Jewish European or Ashkenazic origin, but not in those of Sephardic origin. Although the disease is more common in Caucasians, the incidence in African Americans is increasing.

 

 

 COLLABORATIVE MANAGEMENT

  Assessment

 HISTORY

The nurse collects data on any family history of inflammatory bowel disease (IBD) and previous and current therapy for the illness, as well as dates and types of surgery. Obtaining a diet history is essential. The history should include the client’s usual dietary patterns and the relationship of elimination pat­terns to intolerance of milk and milk products and greasy, fried, spicy, or hot foods. A history of weight loss may be seen in clients with severe disease.

The nurse asks about the symptoms of acute ulcerative co­litis, which often include abdominal pain, cramping, urgency, and diarrhea with up to 10 to 20 liquid, bloody stools per day, as well as anorexia and fatigue. The client is questioned re­garding his or her usual bowel elimination pattern; the color, consistency, and character of stools; and the presence or ab­sence of blood in all stools. The nurse notes the relationship between the occurrence of diarrhea and the timing of meals, pain, emotional distress, and activity. The client is questioned regarding extraintestinal symptoms such as arthritis, mouth sores, vision problems, and skin disorders.

   PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

The client with ulcerative colitis may have symptoms that vary with the acuteness of onset and with complications of the disease process. The client may complain of abdominal pain, bloody diarrhea, and tenesmus (uncontrollable straining). Vi­tal signs are usually withiormal limits in mild disease. In more severe cases, the client may have a low-grade fever (99° to 100° F [37.2° to 37.8° C]). The physical assessment find­ings are typically nonspecific, and in milder cases the physi­cal examination may be normal.

The nurse may note some mild abdominal distention along the colon. Palpation may reveal areas of increased or localized tenderness. Rebound tenderness may suggest peritonitis. The nurse may note localized areas of abdominal pain or cramp­ing over areas of diseased bowel. The client may be febrile and tachycardic, indicating possible complications, such as peritonitis, dehydration, and bowel perforation.

    PSYCHOSOCIAL ASSESSMENT

The intestinal and extraintestinal symptoms associated with ulcerative colitis can be taxing. The nurse evaluates the client’s understanding of the illness and its impact on his or her lifestyle. The client is encouraged and supported while the following are explored:

The relationship of life events to disease exacerbations ■ Stress factors that produce symptoms Family and social support systems Concerns regarding the possible genetic basis and asso­ciated cancer risks of the disease

Many clients are very apprehensive regarding the fre­quency of stools and the presence of blood. The uncontrolla-bility of the disease symptoms, particularly diarrhea, can be disruptive and stress producing. More severe illness may limit the client’s activities outside the home. As a result of the ex­cessive diarrhea, the client may become dependent on the proximity of a bathroom. Eating may be associated with pain and cramping, as well as an increased frequency of stools. Mealtimes may become unpleasant experiences. Frequent visits to health care providers and vigilant monitoring of the colonic mucosa for dysplastic (irregular) changes can be anx­iety provoking.

  LABORATORY ASSESSMENT

As a result of chronic blood loss, hematocrit and hemoglobin levels may be low, reflecting anemia and a chronic disease state. An increased white blood cell (WBC) count and ele­vated erythrocyte sedimentation rate (ESR) are consistent with inflammatory disease. Sodium, potassium, and chloride concentrations may be depleted secondary to frequent diar-rheal stools and malabsorption resulting from the diseased bowel. Hypoalbuminemia is found in clients with extensive disease.

Viral and bacterial dysenteries can cause symptoms simi­lar to those of ulcerative colitis. Before an invasive diagnostic workup, the stools are examined for occult blood, ova (eggs), and parasites, and specimens for culture are obtained. Other problems must be ruled out before a definitive diagnosis of ul­cerative colitis is made.

   RADIOGRAPH1C ASSESSMENT

Barium enemas with air contrast demonstrate differences be­tween Crohn’s disease and ulcerative colitis and identify com­plications, mucosal patterns, and the distribution and depth of disease involvement. In early disease, the barium enema will show incomplete filling as a result of inflammation and fine ulcerations along the bowel contour. These ulcerations appear deeper in more advanced disease.

 OTHER DIAGNOSTIC ASSESSMENT

The sigmoidoscopic examination is probably the most defini­tive diagnostic procedure for ulcerative colitis. The physician can directly visualize the sigmoid and transverse colon. Com­mon findings include an edematous, friable bowel mucosa with a loss of vascular pattern and frequent ulcerations. Biopsy specimens can also be taken to determine if inflam­mation or dysplastic changes are present.

 CRITICAL THINKING CHALLENGE

 A 65-year-old female client is admitted to your unit with a 10-year history of mild to moderate ulcerative colitis. Re­cently she has noted an increasing amount of abdominal pain and cramping following meals. She has also experienced an increase in stools from 1 to 3 per day to 8 to 12 per day. She reports that the stools contain blood and mucus. Her vital signs are normal except for a slight increase in temperature to 100° F (37.8° C).

•  What additional information in the history should you elicit from the client?

•  What actions should you take considering this client’s in­crease in temperature and gastrointestinal (Gl) symptoms?

•  What long-term consequences of the disease is this client most at risk for?

Analysis

 COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

The following are commoursing diagnoses for clients with ulcerative colitis:

1.   Diarrhea related to inflammation of the bowel mucosa

2.   Acute and Chronic Pain related to inflammation and ulceration of the bowel mucosa and accompanying skin irritation

The most common collaborative problem is Potential for Gastrointestinal Bleeding.

ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

In addition to the commoursing diagnoses and collabora­tive problems, clients with ulcerative colitis may have one or more of the following:

•         Imbalanced Nutrition: Less Than Body Requirements related to diarrhea and malabsorption

•         Disturbed Body Image related to increased bowel elimi­nation or surgical intervention

Activity Intolerance related to fatigue and anemia Ineffective Coping related to chronic physical illness and repeated hospitalizations

•  Risk for Deficient Fluid Volume related to diarrhea

•         Impaired Oral Mucous Membrane related to extraintestinal oral disease

•         Anxiety related to increased risk of colon cancer and lifestyle interruptions

 Planning and Implementation

DIARRHEA

Ml PLANNING: EXPECTED OUTCOMES. A major concern for a client with ulcerative colitis is the occurrence of frequent, bloody diarrhea. The client with ulcerative colitis is expected to experience decreased diarrhea through measures to reduce the inflammation of the intestinal lining.

INTERVENTIONS. Many measures are used to relieve symptoms and to reduce intestinal motility, decrease inflam­mation, and promote intestinal healing. Medical management of ulcerative colitis is the preferred and initial treatment option.

NONSURGICAL MANAGEMENT. Nonsurgical manage­ment includes drug and diet therapy. The provision of physi­cal and emotional rest are also important considerations.

 DIARRHEA MANAGEMENT. The purpose of diarrhea management (Chart 58-3) is the prevention and alleviation of diarrhea. It is important to instruct the client with exacerba­tions of diarrhea to record the color, volume, frequency, and consistency of stools to determine the severity of the problem. The nurse, in collaboration with the dietitian, assists in iden­tifying factors that may cause or contribute to diarrhea.

The nurse monitors the skin in the perianal area for irrita­tion and ulceration due to loose, frequent stools. Stool cul­tures may be sent if diarrhea continues. The client and family members are instructed in the appropriate use of antidiarrheal medications. The nurse or assistive nursing personnel weighs the client regularly. In severe exacerbations of the disease, the nurse, in collaboration with the health care provider, performs actions to rest the bowel.

DRUG THERAPY. The health care provider prescribes a combination of drugs, including salicylate compounds, corti-costeroids, immunosuppressants, and antidiarrheals.

Salicylate Compounds. Sulfasalazine (Azulfidine, PMS-Sulfasalazine^) is one of the primary treatments for ulcerative colitis. It is thought to act by inhibiting prostaglandin synthe­sis. These compounds may be administered orally or rectally to reduce inflammation. Sulfasalazine is used to prevent recur­rences of the disease, as well as to treat acute exacerbations of mild to moderate severity (Glickman, 1998). The usual dose of sulfasalazine is 2 to 4 g/day. The nurse teaches the client to take the drug with a full glass of water and to increase fluids throughout the day. The drug should be taken after meals to prevent GI discomfort. Blood dyscrasias, such as leukopenia and anemia, may occur.

Oral mesalamine (Asacol, Pentasa, Salofalk’*’) is used for its anti-inflammatory effect in the acute phase of the illness. The recommended dose of Asacol is 800 mg three times a day or Pentasa 4 g daily in divided doses. Tablets should not be crushed, broken, or chewed. The drug is also available for rec­tal administration.

Olsalazine (Dipentum) 1 g daily is a salicylate used for maintenance therapy. Side effects of oral mesalamine include occasional flare-ups of colitis.

Clients with mild to moderate colitis of the distal bowel may be treated with mesalamine suppositories given two or three times daily or with retention enemas (Rowasa enema) given once daily at bedtime.

Corticosteroids. Oral or IV corticosteroid therapy may be prescribed during exacerbations of the disease. Prednisone (Deltasone, Winpred) 40 to 65 mg daily is usually given orally. For a severely ill client, prednisolone (Delta-Cortef) 45 to 60 mg daily may be given intravenously. Once clinical im­provement has been established, the corticosteroids are ta­pered over a 2- to 3-month period following discharge be­cause of the long-term adverse effects that commonly occur with steroid therapy. Examples include hyperglycemia (in­creased blood glucose), osteoporosis, peptic ulcer disease, and increased risk for infection. For clients with rectal symp­toms, topical steroids in the form of small-retention enemas may be prescribed. Hydrocortisone rectal foam (Cortifoam) is ordered one to two times daily for 2 to 3 weeks, then every other day. Hydrocortisone enemas (Cortenema) are given at bedtime for 21 days, then tapered and discontinued.

Immunosuppressive Drugs. As single agents, immuno-suppressive drugs are not effective in the treatment of ulcera­tive colitis. However, when given in combination with steroids, they may help to reduce the amount of steroids nec­essary to obtain a response. Cyclosporine given at 4 mg/kg/day can be beneficial in severely ill clients who might otherwise require a colectomy. Oral mercaptopurine (Purinethol) may be given at a dose of 1.5 to 2.5 mg/kg/day. The nurse observes for side effects of this medication, which include thrombocytope-nia (decreased platelets), leukopenia (decreased white blood cells [WBCs]), anemia, renal failure, infection, headache, GI ulceration, stomatitis (oral cavity inflammation), and hepato-toxicity. Therefore it is important to monitor blood counts and note signs of infection.

Antidiarrheal Drugs. To provide symptomatic manage­ment of diarrhea, antidiarrheal drugs may be ordered. These drugs are given very cautiously, however, since they can pre­cipitate colonic dilation and toxic megacolon. Common an­tidiarrheal drugs include diphenoxylate hydrochloride and at-ropine sulfate (Lomotil) and loperamide (Imodium).

 

DIET THERAPY. The severity of the client’s ulcerative co­litis determines the type of diet required. Clients may begin with one form of diet therapy and progress to a more ad­vanced diet as symptoms diminish, with the goal of prevent­ing hyperactive bowel activity. Clients with severe symptoms are kept on NPO status to ensure bowel rest. The physician often orders total parenteral nutrition (TPN) for these clients (see Chapter 61). Clients with slightly less severe symptoms may be given elemental formulas, such as Vivonex or Ensure, which are absorbed in the upper bowel, thus minimizing bowel stimulation. Clients with significant but less severe symptoms may be restricted to a low-fiber (low-residue) diet. Clients following a low-fiber diet should avoid foods such as whole-wheat grains, nuts, and fresh fruits or fresh vegetables (Table 58-4). There is contro­versy whether fiber needs to be restricted during the chronic phase of the illness. If fiber intake does not induce symptoms, the intake of fiber need not be limited. However, because the role of diet in inflammatory bowel disease (IBD) is not well defined, and because individual tolerance to foods vary, clients with controlled symptoms may only need to limit or omit those foods that cause them discomfort or diarrhea. Typically, lactose-containing foods are poorly tolerated and should be reduced or eliminated. All clients should be cautioned that caffeinated beverages, pepper, alcohol, and smoking

are common GI stimulants that could cause discomfort.

 

REST. At the onset of treatment, activity is generally restricted because rest can reduce intestinal activity, provide comfort, and promote healing. The nurse ensures that the client has easy access to a bedpan, commode, or bathroom in case of urgency or tenesmus.

SURGICAL MANAGEMENT. Approximately 20% to 25% of individuals with ulcerative colitis require a colectomy (Glickman, 1998). Indications for surgery include bowel per­foration, toxic megacolon, hemorrhage, colon cancer, and conventional treatment failure. The surgeon may choose one of several surgical procedures to alleviate these problems.

TOTAL PROCTOCOLECTOMY WITH A PERMANENT ILEOSTOMY. Total proctocolectomy (or colectomy) with a permanent ileostomy has traditionally been the standard sur­gical procedure for clients undergoing a colectomy.

Preoperative Care. When an ileostomy is indicated, the nurse provides extensive explanations to the client and family or significant other. Preoperative teaching includes aspects that relate to abdominal surgery (see Chapter 17) and those that relate to ileostomy. The surgeon consults with the en-terostomal therapist (ET) preoperatively for recommenda­tions on the location of the ostomy (stoma). (An ET is a nurse specializing and certified in skin and ostomy care.) A visit from an ostomate (a client with an ostomy) may be appropri­ate before surgery if the client agrees to this. The surgeon or­ders oral or parenteral antibiotics, such as neomycin sulfate (Mycifradin, Neo-fradin), as a bowel antiseptic. Mechanical cleansing of the bowel with enemas or laxatives may also be required.

Operative Procedure. During a total proctocolectomy with a traditional permanent ileostomy, the colon, rectum, and anus are removed, followed by closure of the anus. The sur­geon brings the end of the terminal ileum out through the ab­dominal wall and forms a stoma, or ostomy. The stoma is usu­ally placed in the right lower quadrant of the abdomen, below the belt line (Figure 58-2). The surgeon makes a perineal in­cision to remove the rectum and supporting tissues.

Postoperative Care. Initially after surgery, the output from the ileostomy is a loose, dark green liquid that may contain some blood. Over time, a process called ileostomy adaptation occurs. The small intestine begins to absorb in­creased amounts of sodium and water (a former function of the large intestine, which was removed by surgery). Stool volume decreases, becomes thicker (pastelike), and turns yellow-green or yellow-brown. The effluent (fluid material) usually has little odor or a sweet odor. Any foul or unpleas­ant odor may be a symptom of some underlying problem (e.g., blockage or infection).

Depending on the frequency and irritation of stool drainage, the client must wear a pouch system at all times. Disposable systems are most often used.

Prevention of skin problems (irritation, excoriation, ulcer–ation) is critical for the client with an ileostomy. The output from the small intestine is rich in proteolytic enzymes and bile salts, which can quickly irritate and injure the skin. A pouch system that has some type of skin barrier (gelatin or pectin) provides sufficient protection for most clients. Other products are also available.

Most clients undergoing surgical intervention for ulcera­tive colitis have lived with chronic illness for some time. They may view surgery positively as a relief from the multiple problems caused by the disease. Initially, however, they may not perceive life with an ileostomy as a positive alternative.

Total proctocolectomy with a permanent ileostomy results in an alteration in appearance and body function. The goals for a client undergoing this procedure are to become proficient in self-care, to adapt his or her lifestyle to include care of an os­tomy, and to successfully resume presurgery activities.

TOTAL COLECTOMY WITH A CONTINENT ILEOS­TOMY. As an alternative to the traditional ileostomy with an external pouch, the surgeon may create an internal system—a Kock’s ileostomy or ileal reservoir. This procedure is some­times referred to as a continent ileostomy. The surgeon con­structs an intra-abdominal pouch or reservoir from the termi­nal ileum (Figure 58-3), where stool is stored in the pouch until it is drained by the client using a soft rubber catheter. The care of a Kock’s ileostomy involves the connection of the pouch to the stoma, which is constructed with a nipple-like valve made from an intussuscepted portion of the ileum. The stoma is flush with the skin.

The nursing care of the client undergoing this procedure is similar to the care of the client undergoing a proctocolectomy with a permanent ileostomy (see the previous section). Imme­diately postoperatively, an indwelling Foley catheter is placed in the pouch, which is connected to low intermittent suction and irrigated as ordered.

The nurse monitors the character and quality of effluent (drainage). Approximately 2 weeks after surgery, the nurse teaches the client to drain the stoma. Initially, the pouch holds only 50 to 75 mL; over time, the pouch capacity reaches 500 to 700 mL. When the pouch needs to be emptied, the client experiences a sensation of fullness. The client drains the pouch several times a day and wears a small dressing over the stoma to keep it moist and to protect clothing from the moist stoma. This procedure has several advantages. The client does not need to wear an external pouch for collection of stool and experiences minimal skin problems. Unfortunately, the need for frequent revisions and problems with leakage have made this procedure less desirable.

 

 

TOTAL COLECTOMY WITH ILEOANAL ANASTOMO­SIS; ILEOANAL RESERVOIR. During a total colectomy with ileoanal anastomosis, the surgeon removes the colon and the rectum and sutures the ileum into the anal canal. Usually continence is excellent following this procedure, but up to 20% of clients will have some nocturnal leakage of stool. The nursing care of the client undergoing this procedure is similar to the care of clients undergoing a colectomy. With an ileoanal anastomosis, perineal irritation is a common occur­rence as a result of frequent, loose stools. The nurse should provide careful perineal care. The creation of an ileoanal reservoir has become popular for clients with ulcerative colitis because it spares the rectal sphincter and eliminates the need for an ostomy. During this procedure, the surgeon removes the colon and sutures the ileum into the rectal stump to form a reservoir. If residual rec­tal mucosa remains after either an ileoanal anastomosis or a reservoir procedure, proctoscopy is done at predetermined in­tervals to monitor for dysplasia.

Preoperative Care. The preoperative care for a client undergoing an ileoanal anastomosis is similar to that for a client undergoing an ileostomy. However, clients will not have an ostomy and therefore do not require consultation with an enterostomal therapist (ET).

Operative Procedure. Ileoanal anastomosis occurs in two stages (Figure 58-4). In the first stage, the surgeon ex­cises the rectal mucosa, performs an abdominal colectomy, constructs the reservoir or pouch to the anal canal, and creates a temporary loop ileostomy. The loop ileostomy is necessary to allow adequate healing of the internal pouch and all anas­tomosis sites and to allow for an increase in the capacity of the internal reservoir through fluid instillations. After 3 to 4 months the client returns to have the loop ileostomy closed. Stool formation resembles that in clients who have undergone a traditional ileostomy.

Postoperative Care. The nurse provides the usual post­operative interventions for clients who have undergone ab­dominal surgery. All clients requiring surgical intervention for ulcerative colitis have an abdominal incision. Initially, most clients are maintained on NPO status and a nasogastric (NG) tube is used for suction.

ACUTE PAIN; CHRONIC PAIN

PLANNING: EXPECTED OUTCOMES. The client with ulcerative colitis is expected to experience relief from painful abdominal cramping and skin irritation as indicated by self-report.

INTERVENTIONS. Pain control may be accomplished through pharmacologic and nonpharmacologic measures. The client’s symptoms can cause physical discomfort, which can also contribute to emotional discomfort. The use of a variety of symptom-reducing interventions and supportive measures can provide increased comfort.

 PAIN MANAGEMENT. The purpose of pain management is the alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client (see Chart 58-3). The client with ulcerative colitis experiences abdominal pain and cramping, particularly with exacerbations of the disease. In­creases in pain may also signal the development of complica­tions such as peritonitis. Frequent bowel movements can cause skin irritation and increase the client’s discomfort. The nurse performs a comprehensive pain assessment. With the client and the health care team, the nurse evaluates the effec­tiveness of past pain control measures used.

The nurse assists the client in reducing or eliminating fac­tors that can precipitate or increase the pain experience. Antidiarrheal medications may be prescribed to control diarrhea but must be used cautiously, since they can precipitate toxic megacolon. The client may benefit from diet teaching and meal planning as a means of decreasing abdominal discom­fort related to cramping and bloating. Excoriated skin can contribute to pain and discomfort. Scrupulous skin care pre­vents painful excoriation of the skin. The nurse can also teach the client to use nonpharmacologic measures (e.g., biofeed-back, music therapy, guided imagery) as a means of pain modification.

 

DRUG THERAPY. Antidiarrheal medications are used to control diarrhea and thereby reduce the resulting discomfort. These must be used with caution, since toxic megacolon can develop. The physician may prescribe anticholinergics, such as propantheline bromide (Pro-Banthine), before meals to pro­vide relief from the pain and cramping that may occur with di­arrhea. Opioids are used sparingly and cautiously, since these drugs can mask symptoms of life-threatening complications.

DIET THERAPY. Dietary measures help to control symp­toms and thereby promote relief from discomfort. The nurse assesses the client’s needs for diet teaching and evaluates the effects of implemented dietary measures on an ongoing basis.

PERINEAL SKIN CARE. Perineal skin can be irritated by frequent contact with loose stools and frequent cleaning. This irritation can be a major contributor to the client’s discomfort. The nurse explains special measures for skin care. For exam­ple, cleaning the perineal area with mild soap and warm water after each bowel movement keeps the skin free of any stool.

Frequent sitz baths may be helpful, particularly after a bowel movement. The application of a thin coat of mineral oil, pe­troleum jelly, vitamin A and D ointment, aloe creams, or med­icated foam applications may provide relief. Use of medicated wipes with witch hazel (e.g., Tucks) is soothing if the rectal area is tender or sensitive from the use of toilet tissue.

Various manufacturers of ostomies (e.g., Hollister and Convatec) produce a three-product system for skin care that may help prevent and heal perineal skin irritation, thus reliev­ing discomfort. Such systems include a skin-cleaning solu­tion, a moisturizing and healing cream, and a petroleum jelly-like ointment that prevents contact of moisture and stool with the skin.

POTENTIAL FOR GASTROINTESTINAL BLEEDING

PLANNING: EXPECTED OUTCOMES. The client with ulcerative colitis is expected to experience a reduction in or cessation of the gastrointestinal (GI) bleeding that accom­panies chronic ulcerative colitis. The client is also expected to remain free of complications of the disease that can cause bleeding, such as perforation.

INTERVENTIONS. The nurse’s primary responsibility is to monitor the client closely for signs and symptoms of GI bleeding resulting from acute disease or complications. All stools are monitored for blood, using both gross and occult examination. The nurse monitors the client’s hematocrit, he­moglobin, and electrolyte values for abnormalities. The nurse or assistive nursing personnel monitors the client’s vital signs.

The client is observed for the development of fever, tachycar­dia, fluid volume depletion, electrolyte imbalances, and se­vere abdominal pain. Changes in mental status may be noted, especially among older adults.

If symptoms of GI bleeding are present, the nurse notifies the health care provider immediately, since surgical interven­tion may be necessary. Blood products may be necessary for clients with severe anemia. The nurse readies the client for transfusion by inserting a large-bore IV catheter for the ad­ministration of blood. Chapter 56 describes the management of GI bleeding in detail.

Community-Based Care

The client with ulcerative colitis is managed at home but may require hospitalization during exacerbations. In addition, clients experiencing extraintestinal manifestations of the dis­ease will require ongoing management of joint or skin prob­lems. Clients with moderate to severe ulcerative colitis have more acute exacerbations than those with milder forms of the disease. Such clients may benefit from case manager services to coordinate and facilitate quality care in a cost-effective way.

 HOME CARE MANAGEMENT

For clients with ulcerative colitis, home care management fo­cuses on managing symptoms and monitoring for complica­tions. The nurse instructs the client in measures to reduce or control abdominal pain, cramping, and diarrhea. The nurse also instructs the client and family members regarding symp­toms that should be reported immediately to the health care provider. For clients returning home or transferring to nursing home or subacute care following surgery, ongoing respiratory care, incision care, ostomy care, and pain management are ad­ditional concerns.

 HEALTH TEACHING

The nurse educates the client about the nature of ulcerative colitis with regard to its acute episodes, remissions, and symptom management. The nurse emphasizes that even though the cause is unknown, relapses can be resolved with proper health care.

The nurse teaches the client dietary measures to reduce bloating and cramping. The client needs to learn what foods are best tolerated and adjust his or her diet accordingly. The nurse teaches about prescribed medications and medication side effects to remain alert for. Clients taking immunosup-pressive drugs should be taught to report signs of infection, such as sore throat, to the health care provider. The nurse pre­pares written instructions for the client and family members about the signs of colonic dilation and perforation and reiter­ates the importance of notifying the health care provider if these signs occur.

If the client has undergone a surgical diversion to manage colon effluent, the nurse or enterostomal therapist (ET) ex­plains and demonstrates the required care. The client is en­couraged to demonstrate self-care of the ileostomy. The nurse also teaches clients with an ileostomy to include adequate amounts of salt and water in their diets because the ileostomy promotes the loss of these elements. They are taught to be cautious in situations that promote profuse sweating or fluid loss, such as during strenuous physical activities, when envi­ronmental heat is excessive, and during episodes of diarrhea and vomiting. Chart 58-4 describes ileostomy care in detail.

A client with an ileostomy may have multiple concerns about management at home and about sexual and social ad­justments. Considering possible sexual issues helps the client to identify and discuss these concerns with the sexual partner. Social situations may precipitate some anxieties related to de­creased self-esteem and a disturbance in body image. The nurse helps the client explore possible concerns in addressing and resolving these potentially stressful events.

 HEALTH CARE RESOURCES

If the client requires assistance with activities of daily living, the case manager or social worker may help arrange the services of a home care aide. If the client is discharged from the hospital with an ileostomy, the case manager makes a referral to a home care agency. A home care nurse can provide as­sessment and guidance in integrating ostomy care into the client’s lifestyle and possibly provide wound care, including the monitoring of wound healing (Chart 58-5). The client needs to know where to purchase ostomy supplies, along with the name, size, and manufacturer’s order number. The ET or case manager contacts local and regional supply companies for prices and availability of supplies.

The nurse or ET can identify the local ostomy support group by contacting the United Ostomy Association. A sup­port group or the Crohn’s and Colitis Foundation of America may be of assistance in obtaining supplies, as well as provid­ing education for ostomates. The nurse also informs the client and family or significant others of available ostomy outpatient clinics and ETs. If the client agrees, a visit from an ostomate can be initiated or continued on an outpatient basis.

Evaluation: Outcomes

MB The nurse evaluates the care of the client with ulcerative colitis on the basis of the identified nursing diagnoses and col­laborative problems. Expected outcomes may include that the client will:

·        Be free of diarrhea, rectal bleeding, and cramping

·        Maintain adequate hydration

·        Understand the factors that can influence exacerbations of the disease

·        Maintain ideal body weight

·        Understand and adhere to the prescribed drug regimen Remain free of complications of the disease

·        Identify and seek care for extraintestinal manifestations of the disease

·        In addition, the client with an ileostomy can be expected to:

·        Engage in self-care of the ileostomy

·        Maintain peristomal skin integrity

·        Demonstrate behaviors that integrate ostomy care into his or her lifestyle

·        Verbalize signs and symptoms of stoma complications

Crohn’s Disease

 overview

Crohn’s disease, also known as regional enteritis or granulo-matous colitis, is a chronic inflammatory bowel disease (IBD) that can affect any part of the gastrointestinal (GI) tract, from the mouth to the anus. Approximately one million people in the United States have the disease (Klonowski & Masoodi, 1999). The peak incidence is between 15 and 40 years of age. The cause of Crohn’s disease is uncertain; how­ever, infectious, genetic, and immune etiologies have been proposed.

Mycobacterium paratuberculosis has been proposed as an environmental stimulus that could be implicated in the devel­opment of Crohn’s disease, since granulomas similar to those seen in individuals with pulmonary tuberculosis have been found on biopsy of the intestines of people with the disease. A genetic predisposition to the disease has also been proposed, since the disease tends to cluster in families and appears equally in identical twins. However, the most widely accepted cause is believed to be a defect in the immunoregulation of inflammation in the presence of bacteria or viruses in the intes­tinal tract, along with a genetic predisposition for the disease (Norton, 1998).

Chronic, nonspecific inflammation of the entire intestinal tract characterizes the disease, with the terminal ileum being the site most often affected. Eventually, deep fissures and ul-cerations develop and often extend through all bowel layers, predisposing the individual to the development of bowel fis­tulas. The result is severe diarrhea and malabsorption of vital nutrients. Chronic pathologic changes include thickening of the bowel wall, resulting iarrowing of the bowel lumen and strictures. In advanced disease, the bowel mucosa demon­strates nodular swelling (granulomas) intermingled with deep ulcerations.

The complications associated with Crohn’s disease are similar to those of ulcerative colitis. As shown in Table 58-3, hemorrhage is more common in ulcerative colitis but can occur in Crohn’s disease as well (see the Evidence-Based Practice for Nursing box on p. 1284). Severe malab­sorption by the small intestine is more common in clients with Crohn’s disease. Cancer of the small bowel and colon may develop in the client with Crohn’s disease but usually occurs after the disease has been present for 15 to 20 years. Fistula formation is a common complication of Crohn’s dis­ease. Fistulas can occur between segments of the intestine or present as cutaneous fistulas or perirectal abscesses. Fistulas can also extend from the bowel to other organs and body cavities, such as the bladder or vagina (Figure 58-5). Twenty to thirty percent of individuals with the disease will develop intestinal obstruction. Initially, obstruction results from in­flammation and edema. Over time, fibrosis develops and ob­struction results secondary to a narrowing of the bowel (Glickman, 1998).

 

The purpose of this study was to assess the characteristics of clients with lower gastrointestinal (Gl) bleeding related to Crohn’s disease. In this study, 34 clients presenting to the hospital with lower Gl bleeding were identified and data con­cerning the following characteristics were analyzed: client characteristics, blood transfusion requirements, site of bleed­ing, treatment, and follow-up.

In eight clients, the first manifestation of Crohn’s disease was an episode of severe bleeding. Clients received 1 to 5 units of blood. The hemorrhage was found to be more fre­quent in clients with colonic disease than in those with dis­ease confined to the small bowel. In 95% of cases, bleeding was caused by an area of ulceration, usually found in the sig-moid colon. Treatment consisted of blood transfusions and supportive measures such as corticosteroids, immunosup-pressants, or endoscopy to identify the lesion and to apply ei­ther laser coagulation or adrenaline to stop bleeding from the lesion. Treatment was successful in 80% of clients with a first-time bleed. Bleeding was not significantly associated with steroid therapy in this study. In follow-up, 12 clients experi­enced recurrent bleeding episodes.

Critique. The relatively small sample size and convenience sampling method limits the generalizability of the findings. The definition and severity of Gl bleeding may vary across the sev­eral medical centers used for subject recruitment, although the authors attempted to standardize this by recruiting sub­jects who received 2 or more units of blood.

Implications for Nursing. Although the results of the study cannot be generalized to all clients with Crohn’s disease, new data about the presentation of the disease and its course were presented. The characteristics of hemorrhagic forms of Crohn’s disease are not well described in the literature. This study can serve to make nurses more aware of bleeding as a complication more often associated with the disease than was previously thought. Nurses who care for individuals with dis­ease in the colon can monitor their clients more closely for Gl bleeding. Also, the study finding that more conservative treat­ments were successful in treating 80% of first-time hemor­rhages can be shared with clients. Finally, although steroids were not associated with the development of bleeding in this study, other medications can increase the risk of Gl bleeding. Clients need to be taught to avoid nonsteroidal anti-inflamma­tory drugs or aspirin-containing products while taking steroids, since the risk of bleeding increases. In addition, concomitant warfarin treatment may also increase the risk of bleeding.

 

 CULTURAL CONSIDERATIONS

Crohn’s disease is more common among people of Jewish descent, Caucasians of Western cultures, and those of middle European origin. The incidence of Crohn’s disease is 20% greater in women than in men.

 COLLABORATIVE MANAGEMENT

Assessment

HISTORY

A detailed history will assist in uncovering signs and symptoms specific to Crohn’s disease. A history of fever, abdominal pain, and loose stools is commonly seen in a client with Crohn’s dis­ease. He or she is asked about recent unintentional loss of weight. The nurse should ask about the frequency, consistency,

 PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

The nurse performs a thorough abdominal examination, as­sesses for clinical manifestations of the disease, and evaluates the client’s nutritional and hydration status. When performing an abdominal assessment, the nurse ofteotes findings that are consistent with those in acute appendicitis (e.g., tender­ness, guarded movement, and a palpable mass in the right lower quadrant).

On inspection of the abdomen, the nurse assesses for dis-tention, masses, or visible peristalsis. Inspection of the peri-anal area may reveal ulcerations or fissures. During ausculta­tion, bowel sounds may be decreased or absent in the client with severe inflammation or obstruction. An increase in high-pitched or rushing sounds may be present over areas of nar­rowed bowel loops. Muscle guarding, masses, rigidity, or ten­derness may be noted on palpation.

The clinical presentation of Crohn’s disease can vary greatly from client to client. Depending on the parts of the bowel involved, the nurse may identify several clinical mani­festations. Most clients report diarrhea, abdominal pain, and low-grade fever. Fever is also commonly present with com­plications such as fistulas and severe inflammation. If the dis­ease occurs only in the ileum, diarrhea occurs five or six times per day, often with a soft, loose stool. Steatorrhea (fatty diar-rheal stools) is common. The stool may contain bright red blood, but this is a rare finding.

Abdominal pain from the inflammatory process is usually constant and is located in the right lower quadrant. Clients also experience periumbilical pain before and after bowel movements. If the lower colon is diseased, pain is often expe­rienced in both lower abdominal quadrants.

Weight loss is experienced by approximately 80% of indi­viduals with Crohn’s disease. Clients often experience nutri­tional problems as a result of increased catabolism secondary to chronic inflammation, anorexia, malabsorption, or self-imposed dietary restrictions. The result is fluid and electrolyte imbal­ances, as well as protein, iron, vitamin, and mineral deficiencies.

The marked inflammatory bowel changes decrease the small bowel’s ability to absorb nutrients, which may be wors­ened by surgery and fistulas. The nurse is acutely aware of how important it is to detect clinical manifestations of peri­tonitis, bowel obstruction, and nutritional and fluid imbal­ances. The early detection of a change in the client’s status helps to minimize these life-threatening complications.

  PSYCHOSOCIAL ASSESSMENT

The client experiencing Crohn’s disease needs a complete psychosocial assessment. The chronicity of the problem and the troublesome complications can greatly affect clients and their families. The assessment should be ongoing and should continuously reflect the client’s status, as well as the family’s.

DIAGNOSTIC ASSESSMENT

The health care provider may order a number of laboratory studies for clients with Crohn’s disease; however, no disease-specific tests are available to confirm the diagnosis. The resuits of laboratory tests often indicate the extent and severity of inflammation associated with the disease.

If bleeding is present, the client may experience anemia. The nurse may note decreased hemoglobin and hematocrit values as a result of slow blood loss. Serum levels of folic acid and cobal-amin (vitamin B_]2 group) are generally low because of malab-sorption, further contributing to anemia. Amino acid malab-sorption may result in decreased albumin levels. An elevated erythrocyte sedimentation rate (ESR) is consistent with the presence of inflammation. White blood cells (WBCs) in the urine may indicate infection (pyuria), which may be caused by ureteral obstruction or an enterovesical (bowel to bladder) fis­tula. If significant diarrhea is present, the client will experience electrolyte losses, particularly potassium and magnesium.

The results of the contrast barium enema and upper gastroin­testinal (GI) series often provide more specific diagnostic infor­mation. X-ray studies show narrowing, ulcerations, strictures, and fistulas consistent with Crohn’s disease. In the acute illness, these tests are often deferred until the risk of perforation lessens.

Depending on which areas of the bowel are diseased, the sigmoidoscopic examination may not be diagnostic. If the rectosigmoid colon is involved, the physician may see ulcera­tions and inflamed mucosa, areas of fissure, fistula, and ab­scess formation of the perianal and perirectal areas.

Colonoscopy is used when other tests, especially the bar­ium enema examination, have not led to a specific diagnosis.

 

 Interventions

Treatment of Crohn’s disease is similar to that described earlier under Nonsurgical Management (Ulcerative Colitis), p. 1276.

NONSURGICAL MANAGEMENT. Specific interventions vary with the severity of disease and complications present.

DRUG THERAPY. The drugs used to manage Crohn’s dis­ease are similar to those used in the treatment of ulcerative co­litis (see Drug Therapy [Ulcerative Colitis], p. 1277). Sul-fasalazine (Asulfidine, PMS-Sulfasalazine^) 1.5 to 2 g twice a day PO has been shown to be effective in treating exacerba­tions of Crohn’s disease. Although glucocorticoids can be ef­fective, sepsis can result from abscesses or fistulas that may be present. These medications mask the symptoms of infec­tion; therefore they must be used with caution and require vigilant monitoring by the nurse for signs of infection.

Metronidazole (Flagyl, Novonidazol^¹) 250 to 500 mg three times a day PO has been helpful in clients with fistulas. Im-munosuppressive therapy has been effective in clients with re­fractory disease or fistulas. Azathioprine (Imuran), an immuno-suppressive agent, 50 mg/day for 12 months may be instituted. After that time the health care provider may attempt to withdraw the drug, but long-term therapy may be needed in some cases.

Since a defect in immunoregulation of inflammation may be implicated in the development of Crohn’s disease, neutral­ization of a cytokine (specifically, tumor necrosis factor) may prove useful in decreasing bowel inflammation. A relatively new drug, infliximab (Remicade) a chimeric monoclonal an­tibody form of antitumor necrosis factor alpha, has been ap­proved for use. The usual dose of 5 mg/kg has demonstrated efficacy in the treatment of active Crohn’s disease and fistu­las. Further investigation is needed to determine the long-term safety and efficacy of the drug (Mikula, 1999).

NUTRITIONAL MANAGEMENT. Long-standing nutri­tional deficits can have severe consequences for the client with Crohn’s disease. Malnutrition can result in poor fistula and wound healing, loss of lean muscle mass, decreased im­mune system response, and increased morbidity and mortal­ity. With severe exacerbations of the disease, the health care provider may order hospitalization to provide bowel rest and nutritional enhancement with total parenteral nutrition (TPN). For less severe exacerbations, the health care provider may prescribe an elemental diet using products such as Vivonex to induce remission. Elemental diets are absorbed in the jejunum and therefore permit rest of the distal small intestine and colon. Once remission is achieved, the health care provider will usually prescribe a low-residue diet. Nutritional supple­ments, such as Ensure or Sustacal, can be added to provide nutrients and added calories.

COMPLICATION MANAGEMENT. Fistulas (abnormal tract from intestine to skin or intestine to intestine) are com­mon occurrences with acute exacerbations of Crohn’s disease. Clients with fistulas often experience complications, such as systemic infections, skin problems, malnutrition, and fluid and electrolyte imbalances. Treatment of the client with a fis­tula is multidimensional and includes nutrition and electrolyte therapy, skin care, and prevention of infection.

ELECTROLYTE THERAPY. Establishing adequate nutri­tion and fluid and electrolyte balance takes priority in the care of the client with a fistula. GI secretions are high in volume, electrolytes, and enzymes. The client is at high risk for mal­nutrition, dehydration, and hypokalemia. The nurse assesses for these complications and collaborates with the health care team to manage them.

The physician orders fluids and electrolyte replacement by oral liquids and nutrients, as well as IV fluids. An antidiar-rheal agent, such as diphenoxylate hydrochloride or atropine sulfate (Lomotil), may be prescribed to decrease fluid loss from diarrhea, but these drugs are not commonly used and must be given with caution.

When a fistula begins to develop, the client’s nutritional sta­tus is usually compromised. After the fistula has developed, nutritional status worsens. The client requires at least 3000 calories/day to promote healing of the fistula. If the client can­not take adequate oral fluids and nutrients, the physician may order TPN. In collaboration with the dietitian, the nurse:

·        Carefully monitors the client’s tolerance to diet

·        Assists the client in selecting high-calorie, high-protein, high-vitamin, low-fiber meals

·        Offers enteral supplements, such as Ensure and Vivonex

·        Records food intake for accurate calorie counts

SKIN CARE. Proteolytic enzymes and bile contribute to the problem of skin irritation and excoriation. Skin irritation needs to be prevented; this is usually accomplished through the use of skin barriers, application of pouches, and insertion of drains (Figure 58-6). By applying a pouch to the draining fistula, the nurse prevents skin irritation and can measure the effluent (drainage).

In one approach to drainage management, the nurse covers the area surrounding the fistula with barriers, such as Stoma-hesive or DuoDerm, and then applies a wound drainage sys­tem over the fistula, securing it to the protective dressing. The skin adjacent to the fistula is cleaned with normal saline solu­tion and gently patted dry.

The nurse collaborates with the enterostomal therapist (ET) to provide wound management. Wound drainage must never be allowed to be in direct contact with skin without prompt cleaning, because intestinal fluid enzymes are caustic.

PREVENTION OF INFECTION. Clients with fistulas are at extremely high risk for intra-abdominal abscesses and sepsis. Infra-abdominal fistulas are treated with careful nursing inter­ventions, containment of wound drainage, and antibiotic ther­apy. The nurse observes for subtle signs of infection or sepsis, such as fever, abdominal pain, or change in mental status.

SURGICAL MANAGEMENT. Surgery to remove diseased portions of intestine is controversial for clients with Crohn’s disease because risk for recurrence is considerable. However, those who continue to have symptoms after long-term med­ical treatment and those with complications such as fistulas may undergo a small-bowel resection and anastomosis with or without a colon resection to improve quality of life (see the Legal/Ethical Issues in Health Care box on p. 1287). Stricturoplasty may be performed for bowel strictures related to Crohn’s disease. This procedure, which involves incising along the length of the stricture and suturing the incised area on the horizontal plane, allows for an increase in the bowel diameter. Preoperative and postoperative care for each of these surgical procedures is similar to care for clients un­dergoing other types of abdominal surgery.

 

 

 

 Community-Based Care

The discharge care plan for the client with Crohn’s disease is similar to that for the client with ulcerative colitis (see Community-Based Care [Ulcerative Colitis], p. 1282). The nurse or case manager helps the client with a draining fistula plan for care of the fistula at home.

 HOME CARE MANAGEMENT

The interventions begun in the hospital to manage the disease need to be carried out to some extent in the home. Measures to control the disease and related symptoms and manage nu­tritioeed to be reinforced. Supplies for wound and/or fis­tula care may be required. The client’s home should be arranged so that the client has easy access to the bathroom, as well as privacy to perform fistula care. To ensure adequate nu­trition, the client should have easy access to a well-supplied kitchen of readily prepared foods.

HEALTH TEACHING

The teaching plan for the client with Crohn’s disease is sim­ilar to that for the client with ulcerative colitis. He or she is taught the usual course of the disease, symptoms of com­plications, and when to notify the health care provider. Medication teaching, including purpose, dose, and side ef­fects, is incorporated into the teaching plan. The nurse, in collaboration with the dietitian, teaches the client to follow a low-residue, high-calorie diet and to avoid foods that cause discomfort.

The nurse teaches the client to provide for rest periods, es­pecially during exacerbations of the disease. If stress appears to increase symptoms of the disease, the nurse may teach the client stress management techniques or recommend counsel­ing. For long-term follow-up, the client is educated regarding the increased risk of bowel cancer and the advisability of having a colonoscopy yearly as a means of early detection of changes in the mucosa (Hirsch & Caswell, 1999).

If a client has developed a fistula, the nurse explains and demonstrates fistula care. The client needs opportunities to practice the care in the hospital. Ideally, the client should be independent in fistula care before leaving the hospital. How­ever, because of the perirectal or vaginal location of the fistula or an obese abdomen, the client may need assistance in this care. If this is the case, a family member or a caregiver must learn and practice the care, or the nurse or case manager can arrange for home care services.

HEALTH CARE RESOURCES

The client discharged to home following resection and anas­tomosis may require visits from a home care nurse to assess the surgical wound and monitor for complications. The nurse assesses the client’s and family’s ability to monitor the progress of fistula healing and to watch for signs and symp­toms of infection and sepsis. Home care nursing visits may also be appropriate for this purpose. A home care aide might be considered for clients who cannot meet their nutritional needs, who need help with meal preparation, and who need help in purchasing groceries.

If the client needs equipment for fistula care, such as skin barriers and wound drainage bags, the nurse or case manager contacts medical supply companies or local pharmacies to as­certain their availability and price (see the Cost of Care box above). A support group sponsored by the United Ostomy As­sociation or a local hospital in the community may also be available to assist the client and family with physical, as well as psychosocial, needs.

Diverticular Disease

OVERVIEW

Diverticula are congenital or acquired pouchlike herniations of the mucosa through the muscular wall of the small intestine or colon. Diverticulosis is the presence of many abnormal pouchlike herniations (diverticula) in the wall of the intestine. Diverticulitis is the term used to describe an inflammation of one or more diverticula.

 Pathophysiology

Diverticula can occur in any part of the small or large intes­tine, but they occur most commonly in the sigmoid colon (Figure 58-7). The musculature of the colon hypertrophies, thickens, and becomes rigid, and herniation of the mucosa and submucosa through the colon wall is seen. Diverticula seem to occur at points of weakness in the intestinal wall, of­ten at areas where blood vessels interrupt muscular continu­ity. The muscle weakness develops as part of the aging process.

In and of themselves, diverticula cause few problems. If undigested food or bacteria become trapped in a diverticulum, however, blood supply to that area diminishes and bacteria in­vade the diverticulum. Diverticulitis results when the divertic­ulum perforates and a local abscess forms. The perforated di­verticulum can also progress to an intra-abdominal perforation with generalized peritonitis.

Bleeding from diverticula can range from minor, localized bleeding to massive hemorrhage. Minor bleeding is often due to localized inflammation in areas of vascular granulation tis­sue at the base of the diverticulum. Hemorrhage can result when a blood vessel is eroded within a diverticulum. Inflam­mation secondary to recurrent diverticulitis can lead to nar­rowing of the bowel lumen, which may result in obstruction. Inflammation can also result in fistulas to other organs, such as the bladder and the vagina.

Diets with small amounts of fiber have been implicated in the development of diverticula in that they cause less bulky stool and possibly constipation. For diverticulosis and diverticulitis to occur, there must be an increase in intraluminal pressure and muscle contractions to move fecal material through the colon.

The etiologic factor in diverticulitis may be retained undi­gested food in diverticula, which compromises the blood sup­ply to that area and facilitates bacterial invasion of the sac.

 Incidence/Prevalence

The incidence of diverticulosis is difficult to determine, but it is estimated that millions of people are affected. Diverticular disease affects one third of adults over age 60 years. Although diverticulosis is common, only 1 out of 5 people with this dis­ease displays symptoms. Diverticular disease occurs more of­ten in men than in women (Isselbacher & Epstein, 1998).

considerations for older adults

The incidence of diverticula increases with age. There is a reported incidence of 20% to 50% in Western populations over the age of 50 (Isselbacher & Epstein, 1998).

COLLABORATIVE MANAGEMENT

Assessment

 HISTORY

Clients with diverticulosis are usually asymptomatic, and un­less pain and/or bleeding develops, the condition may go un-diagnosed or be found incidentally on routine colonoscopy. Occasionally, diverticulosis causes symptoms. For clients with uncomplicated diverticulosis, the nurse asks about a his­tory of intermittent pain in the left lower quadrant and a his­tory of constipation. If diverticulitis is suspected, the client is asked about a history of fever and abdominal pain. The nurse inquires about recent bowel elimination patterns, since con­stipation may develop as a result of intestinal inflammation. The client is also questioned about the presence of bleeding from the rectum.

  PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

On physical examination of the client with uncomplicated di­verticulosis, no clinical manifestations of the disorder may be present. Occasionally the nurse may elicit tenderness on ab­dominal palpation.

The client with diverticulitis has abdominal pain, most of­ten localized to the left lower quadrant. The pain may be in­termittent at first but becomes progressively steady. Occa­sionally pain may be suprapubic or may occur on one side. Abdominal pain is generalized if peritonitis has occurred. The client’s temperature is elevated, ranging from a low-grade fever to 101° F (38.2° C), and may be accompanied by chills. The nurse may note the presence of tachycardia secondary to fever. Nausea and vomiting are also commonly present.

On examination of the abdomen, the nurse may observe distention. Tenderness on palpation may be noted over the area involved (usually the left lower quadrant). The colon may be palpable. If localized peritoneal irritation is present, local­ized muscle spasm, guarded movement, and rebound tender­ness are usually present. If generalized peritonitis is present, abdominal muscle spasm, guarding, and rebound tenderness are more diffuse.

If the perforated diverticulum is close to the rectum, the health care provider may palpate a tender mass during the rec­tal examination. Blood pressure checks may show orthostatic changes. If bleeding is massive, the client may have hypoten­sion and dehydration that result in shock. If generalized peri­tonitis has occurred, sepsis and manifestations of hypotension and septic or hypovolemic shock can occur.

 

  DIAGNOSTIC ASSESSMENT

For the client with uncomplicated diverticulosis, laboratory studies are not indicated. The client with diverticulitis, how­ever, has an elevated white blood cell (WBC) count. Decreased hematocrit and hemoglobin values are noted if chronic or se­vere bleeding is present. In stool tests for occult blood, results are positive in 20% of clients (also called a positive guaiac). Urinalysis may show a few red blood cells (RBCs) if the left ureter is in proximity to a perforated diverticulum.

X-ray studies of the intestinal tract with barium contrast show diverticula. An upper gastrointestinal (GI) series shows diverticula of the small intestine, and barium enema examina­tion shows diverticula of the large intestine. X-ray studies are not indicated in clients with uncomplicated diverticulosis, be­cause symptoms are usually minimal or nonexistent.

The client with diverticulitis usually does not undergo a barium enema examination in the acute phase of the illness because of the risk of rupture of the inflamed diverticulum. A barium enema examination may be completed after the client has been treated with antibiotics and the inflammation has re­solved. A flat-plate film of the abdomen may reveal free air and fluid in the left lower quadrant, suggesting an abscess or free air under the diaphragm, indicating perforation. The health care provider may also order a computed tomography (CT) scan to diagnose an abscess or thickening of the bowel related to diverticulitis.

Ultrasonography, a noninvasive test, may reveal bowel thickening or an abscess. The physician may perform a sig-moidoscopy or colonoscopy after the acute phase of the ill­ness, usually to rule out the presence of a tumor in the large intestine, particularly if the client has rectal bleeding. If the sigmoidoscope or colonoscope enters a diverticulum, how­ever, the chances of perforating the diverticulum are high.

Interventions

Clients may be treated on an ambulatory care basis when symp­toms are mild, with a temperature lower than 101° F (38.2° C) and a WBC count ranging from 13,000 to 15,000/mm³. The client who is an outpatient should be monitored for any pro­longed or increased fever, abdominal pain, or blood in the stool. Clients with moderate to severe diverticulitis require hos-pitalization. Clinical manifestations that suggest the need for admission are a temperature higher than 101° F (38.2° C), persistent abdominal pain for more than 3 days, or evidence of lower GI bleeding.

NONSURGICAL MANAGEMENT. For the client with di­verticulitis, a combination of drug and diet therapy with rest to decrease inflammation and improve tissue perfusion is in­dicated. This plan is preferred for older adults and others with mild to moderate disease (Chart 58-6).

DRUG THERAPY. For clients with mild diverticulitis, the health care provider prescribes broad-spectrum antibiotics, such as metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (Bactrim, Septra) or ciprofloxacin (Cipro). A mild analgesic may be given for pain.

The health care provider admits clients with more severe pain to the hospital and orders IV fluids to correct dehydra­tion, as well as IV antibiotics such as cefoxitin plus metronidazole. Anticholinergics, such as propantheline bromide (Pro-Banthine), may reduce intestinal hypermotility. For clients with moderate to severe diverticulitis, an opioid anal­gesic, such as meperidine hydrochloride (Demerol) or mor­phine sulfate, can alleviate pain.

Laxatives are avoided because they increase intestinal motil-ity. Enemas are avoided because they increase intraluminal pressure. The nurse assesses the client for clinical manifesta­tions of fluid and electrolyte imbalance on an ongoing basis.

REST. The nurse instructs the client to remain in bed dur­ing the acute phase of illness. He or she is advised to refrain from lifting, straining, coughing, or bending to avoid an in­crease in intra-abdominal pressure, which can result in perfo­ration of the diverticulum.

DIET THERAPY. During the acute phase of the illness, the client’s diet is restricted to clear liquids. Clients who have more severe symptoms are admitted to the hospital and are kept on NPO status. A nasogastric (NG) tube is inserted if nau­sea, vomiting, or abdominal distention is severe. The nurse ad­ministers IV fluids, as ordered, for hydration. In collaboration with the dietitian, the client increases dietary intake slowly as -symptoms subside. When inflammation has resolved and bowel function returns to normal, a fiber-containing diet is in­troduced gradually. If active diverticulitis recurs, fiber intake is stopped for the acute phase of the illness.

SURGICAL MANAGEMENT. The client with divertic­ulitis may need to undergo surgery for any of the following conditions:

•  Rupture of the diverticulum with subsequent peritonitis

•  Pelvic abscess

•  Bowel obstruction

•  Fistula

•  Persistent fever or pain after 4 days of medical treatment

•  Uncontrolled bleeding

The surgeon performs emergency surgery if peritonitis, bowel obstruction, or pelvic abscess is present. Colon resec­tion, with or without a colostomy, is the most common surgi­cal procedure for clients with diverticular disease.

PREOPERATIVE CARE. Preparation of the client for sur­gery depends on the severity of the condition. The surgery might be performed on an emergency basis, or it might be done with a few weeks’ notice. The surgeon informs the client whether a temporary or permanent colostomy might be required.

If the client is not in the acute stage of diverticulitis, a thor­ough bowel preparation may be given, consisting of enemas and laxatives daily for 2 to 3 days before surgery. Because of the risk of perforation, however, the surgeon may forgo an ag­gressive bowel preparation. If the client has an acutely in­flamed diverticulum or persistent fever and abdominal pain, the bowel preparation is most likely withheld.

The client who is to undergo emergency surgery or who has not responded to medical intervention is maintained on NPO status with an NG tube in place. He or she receives IV fluids with appropriate electrolyte replacements.

For clients without acute inflammation, a well-structured preoperative diet is ordered. The client usually has a low-fiber diet for 4 to 5 days, followed by a full-liquid diet for 2 days, then a clear-liquid diet the evening before surgery.

Preoperative teaching may include information about the possible need for a colostomy. If a colostomy is a possible outcome, the enterostomal therapist (ET) or office nurse de­scribes its function and purpose. The nurse need not discuss colostomy care in detail unless the client wishes this informa­tion at this time.

OPERATIVE PROCEDURES. In a resection of the colon, the surgeon excises the portion that is inflamed or diseased and, if possible, creates an anastomosis of the colon to restore patency. Inflammation and infection, however, may preclude the feasibility of an anastomosis. If this is the case, the sur­geon may perform a colostomy. Select clients may be candi­dates for colostomy closure and anastomosis after the bowel has been allowed to rest for 3 to 6 months.

POSTOPERATIVE CARE. The immediate physical care for clients undergoing a colon resection for diverticulitis is the same as that for clients undergoing abdominal surgery (see Chapter 19).

Wound Care. The client has a drain in place at the ab­dominal incision site for 2 to 3 days. If a colostomy has been performed, the stoma may be covered with petroleum gauze dressing because the colostomy does not drain for approxi­mately 2 days, or a colostomy bag may be placed over the stoma. If the stoma is visible, the nurse monitors its color and integrity. The stoma should be pinkish to cherry red without retraction or prolapse into the abdomen.

Diet Therapy. The client is maintained on NPO status with an NG tube in place for 2 to 3 days after a colon resec­tion with or without a colostomy. When peristalsis returns, the nurse removes the NG tube, according to the health care provider’s order, and introduces clear liquids slowly. Gradu­ally, the diet is advanced to solids, depending on the return of peristalsis and bowel function.

If the client has had a colostomy created, it should begin functioning in 2 to 4 days. Most clients who undergo surgery and colostomy formation for diverticulitis have a sigmoid colostomy because the sigmoid colon is the most common site of diverticulitis. Drainage from a sigmoid colostomy initially consists of loose stool, but eventually the stool becomes formed. A tight seal around the stoma is essential to avoid contact of fe-ces with the skin. Colostomy care is detailed in Chapter 57.

Emotional Support. If a colostomy has been performed, the nurse gives the client an opportunity to express feelings about the ostomy. The nurse discusses these feelings with the client, acknowledging that anger and depression are normal re­sponses. When the client is physically able, the nurse encour­ages him or her to look at the stoma and touch the apparatus.

Community-Based Care

The length of hospitalization for clients with diverticulitis ranges from 4 to 10 days, depending on the response to med­ical treatment and the need for surgery. Discharge plans vary according to the treatment.

 HOME CARE MANAGEMENT

For the client with diverticulitis who has responded to med­ical treatment, home care focuses on proper diet. The nurse assesses the client’s ability to obtain and prepare the recommended high-fiber foods. The client who has required surgi­cal intervention has the added responsibilities of incision care and possibly colostomy care, with some temporary limita­tions placed on activities.

 HEALTH TEACHING

DIET THERAPY. All clients with diverticular disease re­quire education regarding a high-fiber diet. For clients with diverticulosis, an increase in dietary fiber can regulate bowel function and bring about partial relief of symptoms. The nurse and dietitian encourage the client with diverticulosis to eat a diet high in cellulose and hemicellulose types of fiber. These substances can be found in wheat bran, whole-grain breads, and cereals. The client should ingest at least 25 to 35 g of fiber per day. This requirement can be derived from four slices of 100% whole-wheat bread and a 3-ounce serving of all-bran cereal. The nurse also teaches the client to eat fresh fruits and vegetables with high-fiber content to add bulk to stools.

The client who is not accustomed to eating high-fiber foods should add them to the diet gradually to avoid flatulence and abdominal cramping. If the client cannot tolerate the recom­mended fiber requirement, a bulk-forming laxative, such as psyllium hydrophilic mucilloid (Metamucil), can be taken to increase fecal size and consistency. An adequate intake of flu­ids will help to prevent the bloating that may accompany a high-fiber diet. The client should also avoid alcohol because it irritates the bowel. Clients are instructed to avoid foods con­taining seeds or indigestible material that may block a diver-ticulum, such as nuts, corn, popcorn, cucumbers, tomatoes, figs, strawberries, and caraway seeds. In collaboration with the dietitian, the nurse teaches the client that dietary fat intake should not exceed 30% of the total daily caloric intake.

Clients should avoid all fiber when they have symptoms of diverticulitis because high-fiber foods are irritating. As diver-ticulitis resolves, fiber can gradually be added until progres­sion to a high-fiber diet is once again obtained. The client who has undergone surgery is usually taking solid food by the time of discharge from the hospital.

The nurse explains the usual disease course and factors that can exacerbate the disease to the client. Follow-up with the health care provider approximately 1 month following resolu­tion of symptoms is recommended, and a repeat flexible sig-moidoscopy or barium enema may be preformed at that time.

SURGICAL FOLLOW-UP. Clients who have had ab­dominal surgery need oral and written instructions on incision care and the signs and symptoms to report to the health care provider. These are similar to the instructions given to clients after other types of abdominal surgery. The nurse provides in­structions on colostomy care for clients who have a temporary or permanent colostomy.

GENERAL INSTRUCTIONS. The nurse instructs clients with any type of diverticular disease, orally and in writing, about signs and symptoms of acute diverticulitis, in­cluding fever, abdominal pain, and bloody, mahogany, or tarry stools. The client should be advised to avoid the use of laxa­tives (other than bulk-forming types) and enemas. All clients can also benefit from avoiding the activities that increase intra-abdominal pressure, such as straining at stool, bending, or lifting heavy objects. The nurse reassures clients with diverticulosis that this dis­order need not cause problems if a proper diet is followed. The client is informed that this illness does not commonly re­cur and that with proper diet and elimination patterns, recur­ring episodes and potential complications can be avoided.

The client with a colostomy has special needs with regard to the alteration in body image and loss of body function. The nurse encourages the client to verbalize concerns about body image.

Clients who have undergone surgery may need assistance with incision and colostomy care. The nurse or case manager arranges for a home care nurse to assess wound healing and proper functioning of the ostomy and the appliance. If the client is interested, the nurse can arrange for a visit from an ostomy volunteer or an enterostomal therapist (ET). For in­formation about other ostomy resources, the nurse or the client can contact the United Ostomy Association.

ANORECTAL ABSCESS  

 OVERVIEW

Anorectal abscesses most often result from obstruction of the ducts of glands in the anorectal region by feces, foreign bod­ies, or trauma. Stasis of obstructing contents occurs and causes infection that spreads into adjacent tissue. Most abscesses be­gin as cryptitis (a pocket of infection in an anal crypt).

The client may experience diarrhea or rectal pain as the first symptom. There may be no clinical manifestations at the time of the first physical assessment, but local swelling, ery­thema, and tenderness on palpation are apparent within a few days after the onset of pain. If the abscess becomes chronic, discharge, bleeding, and pruritus (itching) may exist. Fever occurs if larger abscesses are present.

COLLABORATIVE MANAGEMENT

Anorectal abscesses are managed by surgical incision and drainage. The physician can often incise simple perianal and ischiorectal abscesses using a local anesthetic. For clients with more extensive abscesses, a regional or general anes­thetic may be needed. Systemic antibiotics are given only for clients who are immunocompromised, are diabetic, have valvular disease or a prosthetic valve, or have extensive sub­cutaneous fat. Incision and drainage in these clients is per­formed after antibiotic therapy.

Nursing interventions are focused on helping the client to maintain comfort and optimal perineal hygiene (Chart 58-7). The nurse encourages the use of sitz baths, analgesics, bulk-producing agents, and stool softeners during the perioperative period until healing occurs. The nurse also emphasizes the importance of ongoing perineal hygiene after all bowel move­ments and the maintenance of a regular bowel pattern with a high-fiber diet.

ANAL FISSURE               ,_r

OVERVIEW

An anal fissure is a superficial erosion of the anal canal. Fis­sures can be primary or secondary, acute or chronic. Primary fissures are idiopathic with no known cause. Secondary fissures are associated with another disorder (e.g., Crohn’s dis­ease, tuberculosis, or leukemia) or with trauma (e.g., from a foreign body, childbirth, or perirectal surgery). Constipated stool, diarrhea, or spasm of the anal sphincter is another pos­sible cause.

 

COLLABORATIVE MANAGEMENT

An acute anal fissure is superficial and resolves sponta­neously or heals quickly with conservative treatment. Chronic fissures recur, and surgical treatment may be needed. Pain during and after defecation and bleeding noted outside the stool are the most common symptoms. Other clinical mani­festations associated with chronic fissures are pruritus, uri­nary frequency or retention, dysuria, and dyspareunia (painful intercourse).

The health care provider makes the diagnosis by inspect­ing and stretching the perianal skin. If the client is having pain at the time of the examination, diagnostic testing is usually limited to inspection. If the client is not in severe pain, a dig­ital examination and possibly a sigmoidoscopy are performed. When painless or multiple fissures are present, the physician may perform a barium enema and sigmoidoscopy to rule out an associated inflammatory bowel disorder.

Management of an acute fissure is nonsurgical, with inter­ventions aimed at local, symptomatic pain relief and softening of stools to reduce trauma to the area. Warm sitz baths and anal­gesia are recommended along with the use of bulk-producing agents, such as psyllium hydrophilic mucilloid (Metamucil), which help minimize pain associated with defecation. If fis­sures do not respond to medical management within several days to weeks, surgical excision of the fissure with a local anes­thetic may be necessary.

The nurse explains the appropriate pain control measures to the client. Wheonsurgical management is initiated, the nurse instructs clients to notify the health care provider if pain is not relieved within a few days. The nurse instructs the client who undergoes surgery to continue with the same pain management and bowel regimen, including sitz baths, analgesics, and bulk forming agents. He or she is reminded to report any drainage or bleeding from the rectum to the health care provider.

 

ANAL FISTULA

I OVERVIEW

An anal fistula, or fistula in ano, is an abnormal tract leading from the anal canal to the perianal skin. Most anal fistulas re­sult from anorectal abscesses, which are caused by obstruc­tion of anal glands (see Anorectal Abscess, p. 1291). Fistulas can also be associated with tuberculosis, Crohn’s disease, or cancer.

COLLABORATIVE MANAGEMENT

The client with an anal fistula has pruritus (itching), purulent discharge, and tenderness or pain that is worsened by bowel movements. The physician uses a proctoscope to identify the source of symptoms and to locate the fistula. Because fistulas do not heal spontaneously, surgery is necessary. To perform a fistulotomy, the surgeon incises the tissue overlying the tract and performs curettage (scraping) of the base. The incision site heals by secondary intention. In a client with a high fis­tula, a special surgical technique is necessary because impor­tant sphincters are often affected. Postoperatively, the nurse instructs the client about sitz baths, analgesics, and the use of bulk-producing agents or stool softeners to minimize pain.

 

PARASITIC INFECTION

OVERVIEW

Parasites can enter and invade the gastrointestinal (GI) tract and cause infections leading to varying degrees of illness. Par­asites commonly enter through the mouth by means of fecal-oral transmission from the following:

·        Contaminated food or water

·        Oral-anal sexual practices

·        Contact with feces from a contaminated person

Common parasites that cause infection in humans are Entamoeba histolytica, which causes amebiasis (amebic dysentery), Giardia lamblia, which causes giardiasis, and Cryptosporidium.

Infection with Entamoeba histolytica

Humans are the only known hosts for E. histolytica (also known as amebiasis). This organism occurs in cysts and trophozoites (sporozoan parasites). Trophozoites die rapidly after they leave the body in stool. Cysts, however, can remain viable in the right type of environment for weeks or months. Humans who eliminate cysts are infectious. Flies have been found to be vectors for transmission of the cysts, and trans­mission is increased in areas that use human excrement for fertilizer. Transmission occurs by the fecal-oral route.

Amebiasis occurs worldwide, but it is most prevalent and most severe in tropical areas. Prevalence rates are as high as 40% in areas with poor sanitation, crowding, and poor nutri­tion. Amebiasis causes 40,000 to 100,000 deaths annually worldwide. The disease causes less severe symptoms and often goes undiagnosed in temperate climates. The organism may oc­cur in 2% to 5% of some populations in the United States. E. histolytica either feeds on bacteria in the intestine or in­vades and ulcerates the mucosa of the large intestine. The par­asite can be limited to the GI tract (intestinal amebiasis), or it can extend outside the intestines (extraintestinal amebiasis). People can have intestinal amebiasis without having any symptoms, or symptoms can range from mild to severe.

Infection with Giardia lamblia

G. lamblia is a protozoal parasite that causes superficial inva­sion, destruction, and inflammation of the mucosa in the small intestine. Like E. histolytica, G. lamblia has a trophozoite and cyst form, and cysts can transmit the organism. Humans are hosts to this organism, but beavers and dogs may be reservoirs for infection. G. lamblia is transmitted by the fecal-oral route. Giardiasis is a well-recognized problem in travelers, campers, male homosexuals, and immunosuppressed people.

Modes of transmission are similar to those for amebiasis; in the United States, however, giardiasis is much more preva­lent and is the most common parasitic infection. Giardiasis af­fects only the intestinal system, causing acute diarrhea, chronic diarrhea, or malabsorption syndrome. The acute phase usually is self-limiting, lasting days or weeks. The chronic phase can last for years. Diarrhea is usually mild in both forms, but it can be severe. As stools increase in fre­quency, they become more watery, greasy, frothy, and mal­odorous with mucus. Weight loss and weakness are also com­mon. Malabsorption can occur with diarrhea that continues for longer than 3 weeks. Manifestations result from malab­sorption of fat, protein, vitamin B₁₂, and lactase deficiency.

Infection with Cryptosporidium

Cryptosporidium is another parasitic infestation transmitted by the fecal-oral route that is manifested by diarrhea. This in­fection commonly occurs in immunosuppressed clients, par­ticularly those with human immunodeficiency virus (HIV). (See Chapter 22 for a discussion of HIV infection.)

COLLABORATIVE MANAGEMENT

Assessment

A thorough history can provide information about potential sources of exposure to parasitic infection. A history of travel to parts of the world where such infections are prevalent in­creases suspicion for infection with parasites. GI symptoms related to travel may be delayed as long as 1 to 2 weeks fol­lowing the return home. A diet history is especially helpful if several people become ill. Common water supplies may be in­fected with Giardia or Cryptosporidium. Trichinosis should be considered if the client has ingested pork products.

Mild to moderate E. histolytica infestation causes clinical manifestations, including the daily passage of several strongly odoriferous stools, possibly with mucus but without blood, accompanied by abdominal cramping, flatulence, fatigue, and weight loss.

Clients experience characteristic remissions and recur­rences. Severe amebic dysentery is manifested by frequent, more liquid, and odoriferous stools with mucus and blood. Fever up to 105° F (40° C), tenesmus (ineffectual and painful straining to defecate), generalized abdominal tenderness, and vomiting can also occur. The ulcerations characteristic of invading amebiasis that occur in the colon can cause pain, bleeding, and obstruction. Ulcerations can also be localized in the rectum, resulting in formed stool with blood. Complica­tions are rare but include appendicitis and bowel perforation.

Extraintestinal amebiasis can occur without symptoms of intestinal infection. The most common form is amebic liver abscess, which causes symptoms of fever, pain, and an en­larged liver. The abscess can rupture, and death can result if the infection is not treated and complications occur.

The diagnosis of amebiasis is made by examination of stool for parasites. Because E. histolytica is difficult to detect, serial stool examinations are needed if the disease is sus­pected. The use of sigmoidoscopy may detect ulcerations in the rectum or colon. Exudate obtained during sigmoidoscopic examination is studied for the parasite. The white blood cell (WBC) count can be as high as 20,000/mm³ when severe dysentery is present.

The diagnosis of giardiasis is also confirmed by stool ex­amination for parasites. Because organisms may not be de­tected for at least 1 week after symptoms appear, multiple stool samples should be examined. Duodenal aspirate can also be examined for the parasite.

Infection with Cryptosporidium is usually self-limiting in individuals who are not immunocompromised. Drug therapy for clients with immunosuppression may consist of paro-momycin 500 to 750 mg four times daily.

Interventions

INTERVENTIONS FOR AMEBIASIS. Treatment for all types of amebiasis mandate the use of amebicide drugs. The physician commonly prescribes metronidazole (Flagyl, Novonidazol*) and diloxanide furoate (Entamide), or dilox-anide furoate and tetracycline hydrochloride (Sumycin) fol­lowed by chloroquine. Clients with severe dysentery require IV fluids for replacement and maintenance of fluid volume and possibly opiates, such as diphenoxylate hydrochloride and atropine sulfate (Lomotil), to control bowel motility. Clients with extraintestinal amebiasis or severe dehydration are hospitalized. Clients with asymptomatic, mild, or moder­ate disease are treated as outpatients with drug therapy. For all clients, at least three stools are examined for parasites at 2- to 3-day intervals, starting 2 to 4 weeks after drug therapy has been completed.

INTERVENTIONS FOR GIARDIASIS. Treatment for gi­ardiasis is drug therapy. Metronidazole is the drug of choice, and the usual dose is 250 mg three times a day PO for 5 days. Tinidazole (Fasigyn) can be used as an alternative. Stools are examined 2 weeks after treatment is begun to as­sess for eradication.

The nurse explains modes of transmission and means to avoid the spread of infection and recurrent contact with para­sitic organisms. Clients are taught that they can transmit the infection to others until amebicides effectively kill the para­sites. The nurse instructs clients to:

•  Avoid contact with stool

•  Keep toilet areas clean

•  Wash their hands meticulously with an antimicrobial soap after bowel movements

•  Maintain personal hygiene

•  Avoid stool from dogs and beavers

The client is also advised to avoid sexual practices that allow rectal contact until drug therapy is completed. The nurse in­forms the client that all household and sexual contacts should undergo stool examinations for parasites. If the water supply is suspected as the source, a sample is obtained and sent for analysis. Multiple infections are common in households, of­ten as a result of contaminated water supplies. Well water and water from areas with inadequate or no filtration equipment can be sources of contamination.

HELMINTHIC INFESTATION

Helminths are wormlike animals; they are often parasitic and capable of causing infectious disease in humans. There are many species of helminths, which, for purposes of classifica­tion, are divided into three general categories:

•  Roundworms (nematodes)

•  Flukes (trematodes)

•  Tapeworms (cestodes)

Helminths can cause various degrees of gastrointestinal (GI) symptoms in humans. Most often, they enter the human body through the skin or via the oral route with ingestion of food, water, or other substances contaminated with worms. Some helminths gain access to the human body via insects, such as flies and mosquitoes. Helminths that are typically transmitted via insects are limited to tropical areas, however, and are not discussed here. Flukes (trematodes), which are passed to humans via snail-contaminated water, are also lim­ited to tropical and subtropical areas outside the United States and are not discussed here.

Roundworms

Roundworms are commonly the cause of helminthic infec­tions in the United States and worldwide. These infections in­clude enterobiasis, trichinosis, and hookworm.

Enterobiasis

Enterobiasis (“pinworm infection”) is caused by Enterobius vermicularis and is the most common helminthic infection in the United States. It is transmitted by oral ingestion of con­taminated food, drink, or fomites. The most common clinical manifestations of infection include nocturnal perianal pruri­tus, vaginitis, insomnia, and restlessness.

The client may have vague GI symptoms, such as abdom­inal pain, nausea, vomiting, and diarrhea. However, many in­fected clients have no symptoms. Diagnosis is made when eggs of the helminth are found on the perianal skin or on cel­lulose tape that has been applied to the perianal skin.

Treatment of enterobiasis includes meticulous handwashing techniques after defecation and before meals to prevent spread of the worms to others. Drug therapy is indicated for all clients with symptoms and in some clients who are infected but are not symptomatic. Household cohabitants of an infected client may be treated with drug therapy even if they are asymptomatic. Pyrantel pamoate (Antiminth, Combantrin^¹) or mebendazole (Vermox, NemasoK’) is given orally in one dose, which is re­peated at 2 and 4 weeks.

Infection with pinworms is curable and is not usually asso­ciated with complications; however, recurrences are common.

Trichinosis

Trichinosis is another helminthic disease caused by round-worms. The incidence in the United States is 50 to 100 cases annually, but many mild or asymptomatic cases are not diag­nosed, since the person is usually asymptomatic. Trichinella spiralis, which lives in the intestine of humans, pigs, bears, and rats, causes trichinosis. The organism is usually transmit­ted to people who ingest undercooked pork or pork products. Ingestion of other meats, such as ground beef, can also pro­mote transmission if a meat grinder has been used for both beef and pork. Following ingestion, the larvae, encased in cysts, are released by the digestive action of acid and pepsin. Incubation is 12 hours to 28 days after ingestion. Clinical manifestations range from none to severe; death rarely results.

During the first week following infection, diarrhea results from the invasion of the gut by large numbers of the parasite. Abdominal pain, nausea, and vomiting may follow. During the second week, the larvae begin to invade the muscle, insti­gating a hypersensitivity reaction characterized by fever, peri-orbital and facial edema, and subconjunctival hemorrhage. Occasionally a rash or dyspnea develops. Two to three weeks after infection, symptoms of myositis, myalgia, and muscle weakness develop, particularly in the lower back, neck, jaw, biceps, and extraocular muscles. Vague muscle pain and malaise characterize the convalescence phase, which can last for several months.

A diagnosis of trichinosis is confirmed by a history of in­gestion of raw or undercooked meat. White blood cell (WBC) and eosinophil counts are elevated for 2 weeks after meat is ingested. Biopsy of skeletal muscle shows larvae of the Trichinella organism. Worms are rarely seen in feces.

During the first week after infection, the client is treated with oral mebendazole. During the stage of muscle invasion, he or she must be hospitalized to receive high doses of corti-costeroids.

Hookworms

Hookworms are also roundworms. They differ from pin-worms and Trichinella in that they initially enter the human body through the skin. Hookworm disease is caused by either Ancylostoma duodenale or Necator americanus.

Hookworms infect a quarter of the world’s population, but the disease is rare in areas outside the tropics or in areas with little rain. Worms are infective outside the body in warm, moist soil for up to 1 week. Transmission occurs when larvae penetrate through the skin. The organism can migrate to pul­monary capillaries via the bloodstream and enter alveoli. Cilia carry the organisms up the respiratory tree to the pharynx and the mouth, where they are swallowed and enter the GI tract. Hookworms probably also enter the GI tract when a person ingests contaminated food.

Early symptoms of hookworm disease include a pruritic, erythematous, raised vesicular inflammation of the skin. In­fection in the GI tract may produce no symptoms, or it may cause anorexia, diarrhea, or mild abdominal and epigastric discomfort. Bleeding and anemia may occur when worms suck blood at sites of attachment in the GI tract. If blood loss is severe, the client may have symptoms of iron deficiency anemia, such as pallor, hair thinning, deformed nails, pica, and shortness of breath.