Practice nursing 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
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
NURSIN<
What are the possible risk factors for irritable bowel syndrome?
Locke, G.R., et al. (2000). Risk factors for irritable bowel syndrome: Role of analgesics and food sensitivities. American Journal of Gastroenterology, 95(1), 157-164.
The purpose of this study was to identify additional risk factors for the development of irritable bowel syndrome (IBS), since previous evaluations of traditional risk factors have not led to insight into the pathogenesis of this disorder. Questionnaires were mailed to an age (30 to 64 years) and gender-stratified sample of 892 individuals residing in
Results showed that 12% of respondents reported IBS symptoms. IBS was significantly associated with the use of analgesics, particularly aspirin. IBS was also correlated with reports of food allergies and ratings of somatic symptoms. The odds of having IBS were higher among subjects taking analgesics and among those reporting multiple food sensitivities.
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 withiormal 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.
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, cauliflower, brussels sprouts)
• Whole-grain products
• Adequate fluids, especially water
Right-sided tumors can grow quite large without disrupting bowel patterns or appearance, since the stool consistency is more liquid in this part of the colon. These tumors ulcerate and bleed intermittently, so stools can contain dark or mahogany-colored blood. A mass may be palpated in the lower right quadrant, and the client often has anemia secondary to blood loss.
Examination of the abdomen begins with assessment for obvious distention or masses. Visible peristaltic waves accompanied by high-pitched or tingling bowel sounds may indicate a partial bowel obstruction from the tumor. Total absence of bowel sounds after listening for 5 full minutes indicates a complete bowel obstruction. Palpation and percussion are performed to evaluate the liver and spleen for enlargement and to evaluate for masses along the colon. The health care provider may perform a digital rectal examination to palpate the rectum and lower sigmoid colon for masses.
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.
INTERVENTION ACTIVITIES/or The Client with Noninflammatory Intestinal Disorders
Grief Work Facilitation: Assistance with the resolution of a significant loss
• Assist the client to identify the nature of the attachment to the lost object or person.
• Assist the patient to identify the initial reaction to the loss.
• Encourage expression of feelings about the loss.
• Instruct in phases of the grieving process, as appropriate.
• Support progression through personal grieving stages.
• Include significant others in discussions and decisions, as appropriate.
• Assist to identify personal coping strategies.
• Encourage client to implement cultural, religious, and social customs associated with the loss.
• Identify sources of community support.
• Assist in identifying modifications needed in lifestyle.
Genetic Counseling: Use of an interactive helping process focusing on assisting an individual, family, or group, manifesting or at risk for developing or transmitting a birth defect or genetic condition, to cope.
• Provide privacy and ensure confidentiality.
• Discuss the client’s purpose, goals, and agenda for the genetic counseling session.
• Discuss the advantages, risks, and costs of genetic tests.
• Monitor response when patient learns about own genetic risk factors.
• Provide referral to genetic health care specialists, as necessary.
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, widespread lesions
• Cecostomy (opening into the cecum with intubation to decompress 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).
BEST PRACTICE/or Perineal Wound Care
Wound Care
• Place an absorbent dressing (Kerlix or abdominal pad) over the wound.
• Instruct the client that he or she may:
Use a feminine napkin as a dressing Wear jockey-type shorts rather than boxers
Comfort Measures
• If ordered, soak the wound area in a sitz bath for 10 to 20 minutes three or four times per day.
• Administer pain medication as ordered and assess its effectiveness.
• Instruct the client about permissible activities. The client should:
Assume a side-lying position in bed; avoid sitting for
long periods Use foam pads or a soft pillow to sit on whenever in a
sitting position Avoid the use of air rings or rubber doughnut devices
Prevention of Complications
• Maintain fluid and electrolyte balance by monitoring intake and output and by monitoring output from the perineal wound.
• Observe suture line integrity and monitor wound drains; watch for erythema, edema, bleeding, purulent drainage, unusual odor, and excessive or constant pain.
CRITICAL THINKING CHALLENGE Your client is about to undergo a colon resection with the creation of a temporary colostomy for colorectal cancer.
• What preoperative teaching should be included for this client?
• What physical parameters should you assess the stoma for in the early postoperative period?
• What postoperative complications should you monitor for?
Community-Based Care
Clients undergoing an uncomplicated colon resection are typically hospitalized for 5 to 7 days. Discharge planning with the assistance of a discharge planner or case manager assists clients and their families in coping with the immediate postoperative phase of recovery. Following hospitalization for surgery, the client with colorectal cancer is usually managed at home. Radiation therapy or chemotherapy is typically done on an ambulatory (outpatient) basis. For the client with advanced cancer, hospice care is an option (see Chapter 9).
■ HOME CARE MANAGEMENT
The nurse assesses all clients for their ability to perform incision care and activities of daily living (ADLs) within limitations. For clients requiring assistance with these activities, home care visits by nurses or assistive nursing personnel can be provided.
For the client who has undergone a colostomy, the nurse or case manager reviews the home situation to aid the client in arranging for care. Ostomy products should be kept in an area (preferably the bathroom) where the temperature is neither hot nor cold (skin barriers may become stiff or melt in extreme temperatures) to ensure proper functioning. The en-terostomal therapist (ET) may serve as a consultant after the client is discharged home to ensure continuity of care.
No changes are needed in sleeping accommodations. A rubber covering may initially be placed over the bed mattress if clients feel insecure about the pouch system. The client may consume his or her usual diet on discharge.
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.
HEALTH CARE RESOURCES
Several resources are available to complement nursing care, maintain continuity of care in the home environment, and provide for client needs that the nurse is not able to meet. The nurse makes a referral to the case manager or social worker, who can provide further emotional counseling to the client and family or significant others, aid in managing the financial concerns that the client and family may have, or arrange home care or extended care (e.g., in a nursing home, group home, or hospice) as needed.
The nurse makes a referral to the enterostomal therapist (ET) to aid in preoperative stoma teaching, evaluate and mark the stoma site, and provide consultation for problems in care. The enterostomal therapist (ET) may also conduct an ambulatory care clinic for ongoing client needs. Information about the United Ostomy Association, a self-help group of people who have ostomies, is provided. Literature, such as the organization’s publication (Ostomy Quarterly), and information about a local chapter are given to the client. This organization conducts a visitor program that sends specially trained visitors (who have an ostomy) to talk with clients. After obtaining the client’s consent, the nurse makes a referral to the visitor program so that the visitor can see the client both preoperatively and postoperatively. A physician’s consent for visitation is generally necessary.
The local division or unit of the American Cancer Society (ACS) can help provide necessary medical equipment and supplies, home care services, travel accommodations, and other resources for the client who is undergoing cancer treatment or ostomy surgery. The nurse informs the client and family of the programs available through the local division or unit.
Because of short hospital stays, clients with new ostomies receive most of their instruction on colostomy care from nurses working for home care agencies. This resource also facilitates provision for physical care needs, medication management, and emotional support for clients with or without colostomies. If the client has advanced colorectal cancer, a referral for hospice services in the home, nursing home, or other long-term care setting may be appropriate. The home care nurse informs the client and family about what ostomy supplies are needed and where they can be purchased. Price and location are considered before recommendations are made.
Evaluation: Outcomes
noo The nurse evaluates the care of the client with colorectal cancer on the basis of the identified nursing diagnoses and collaborative problems. The expected outcomes are that the client:
· Maintains hemodynamic stability following surgeryIs free of infection and postoperative complications
· Demonstrates appropriate incision care and, if applicable, appropriate colostomy care with minimal assistance
· Acquires or maintains effective coping patterns through out the diagnosis, treatment, and rehabilitative phases of recovery
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.
FOCUSED ASSESSMENT of
The Home Care Client with a Colostomy
Assess gastrointestinal status, including:
• Dietary and fluid intake and habits
• Presence or absence of nausea and vomiting
• Weight gain or loss
• Bowel elimination pattern and characteristics and amount of effluent (stool)
• Bowel sounds
Assess condition of stoma, including:
• Location, size, protrusion, color, and integrity
• Signs of ischemia, such as dull coloring or dark or purplish bruising
Assess periostomal skin for:
• Presence or absence of excoriated skin, leakage underneath drainage system
• Fit of appliance and effectiveness of skin barrier and appliance
Assess client’s and family’s coping skills, including:
• Self-care abilities in the home
• Acknowledgment of changes in body image and function
• Sense of loss
Intestinal contents are composed of ingested fluid and saliva; gastric, pancreatic, and biliary secretions; and swallowed air. In both mechanical and nonmechanical obstructions, the intestinal contents accumulate at and above the area of obstruction. Intestinal distention results from the intestine’s inability to absorb the contents and mobilize them down the intestinal tract. To compensate for the lag, peristalsis increases in an effort to move the intestinal contents forward. The increase in peristalsis stimulates more secretions, which leads to additional distention. This causes edema of the bowel with increased capillary permeability. Plasma leaking into the peritoneal cavity and fluid trapped in the intestinal lumen markedly decrease the absorption of fluid and electrolytes into the vascular space. Reduced circulatory blood volume and electrolyte imbalances typically occur. Hypovolemia ranges from mild to extreme (hypovolemic shock).
Specific fluid and electrolyte problems result, depending on the part of the intestine that is blocked. An obstruction high in the small intestine causes a loss of gastric hydrochloride, which can lead to metabolic alkalosis. Obstruction below the duodenum but above the large bowel results in loss of both acids and bases, so that acid-base imbalance is usually not compromised. Obstruction at the end of the small intestine and lower in the intestinal tract causes loss of alkaline fluids, which can lead to metabolic acidosis.
If the resultant hypovolemia is severe, renal insufficiency or even death can occur. Bacterial peritonitis with or without actual perforation can also result. Bacteria in the intestinal contents lie stagnant in the obstructed intestine. This is not a problem unless the blood flow to the intestine is compromised. However, with so-called closed-loop obstruction (blockage in two different areas) or a strangulated obstruction (obstruction with compromised blood flow), the risk for peritonitis is greatly increased. Bacteria without blood supply can form an endotoxin, and release of the endotoxin into the peritoneal or systemic circulation results in septic shock. With a strangulated obstruction, major blood loss into the intestine and the peritoneum can result. Current mortality rates for bowel obstruction range from 3.5% to 6% but may be as high as 14% in older adults.
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
The 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.
Implications for Nursing
There are a variety of diagnostic tests that can be used in confirming the diagnosis of intestinal obstruction. Excessive costs to the health care system occur when an inappropriate diagnostic test is chosen, or if because of inadequate preparation, the examinatioeeds to be repeated. Advanced-practice nurses require a working knowledge of diagnostic testing in order to ensure that their clients undergo the appropriate examination. Nurses responsible for preparing clients to undergo diagnostic procedures should ensure that proper preparation for the examination has been carried out (e.g., bowel prep, maintaining NPO status) to avoid inaccurate or incomplete results requiring the client to undergo additional testing that could add to the client burden and health care costs.
Most health care providers avoid the use of NI tubes because insertion of the mercury-filled lumen is often difficult; the time it takes to insert the tube also delays treatment. Insertion of this tube can be uncomfortable for clients.
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. 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.
Community-Based Care
All clients with intestinal obstruction are hospitalized for monitoring and treatment. The length of stay varies according to the type of obstruction, the treatment, and the presence of complications. Clients who have complicated obstruction, such as strangulation or incarceration, are at greater risk for peritonitis, sepsis, and shock. The hospital stay may be up to several weeks, depending on the severity of complications.
Clients with nonmechanical (adynamic) intestinal obstruction are less likely to require a lengthy hospitalization because of the obstruction alone. Adynamic obstruction generally responds to NG intubation and suction within a few days. The client should be reassured, however, that recurrent paralytic ileus is not usually a problem. The client who has had mechanical obstruction as a result of fecal impaction (often the older adult) needs to have a structured bowel regimen to prevent recurrence (Chart 57-7). The nurse instructs this client to adhere to high-fiber diets, to exercise, and to drink at least 24 ounces of water daily, unless contraindicated. The physician may also order bulk-forming laxatives to help maintain a consistent elimination pattern.
The nurse teaches the client who has had surgery about incision care, drug therapy, and activity limitations. Drug therapy consists of an oral opioid analgesic, such as oxycodone hydrochloride with acetaminophen (Tylox, Percocet, Endo-cef*1), to be taken as needed for incisional discomfort. As with any opioid therapy, a stool softener is added to the medication regimen to prevent constipation and possible recurrent obstruction.
With resolution of obstruction, educational efforts by the nurse are aimed at prevention of obstruction by examining the cause of the obstruction and how to prevent recurrence. The nurse also reinforces important signs and symptoms to report to the health care provider. The client who had curative treatment of the underlying cause most likely requires less support than the client who underwent treatment of obstruction related to a serious disease that will require further treatment. The client is encouraged to express fears and concerns about the future. The nurse assesses the client’s understanding and needs with regard to treatment plans.
HEALTH CARE RESOURCES
The need for follow-up appointments depends on the cause of the obstruction and the treatment required. If the client is at risk for fecal impaction, the nurse can arrange for a home care nurse to assess the gastrointestinal (GI) function and dietary habits of the client on an ongoing basis. Arrangements should also be made for the services of a home care nurse if the client needs help with incision or colostomy care. Medicare guidelines or insurance precertification requirements must be met before approval is given for home care visits. The discharge planner or case manager assist in setting up home care follow-up.
HOME CARE MANAGEMENT
For the client who has had an intestinal obstruction, preparation for home care depends on the cause of the obstruction and the treatment required. Clients who have resolution of obstruction without surgical intervention are assessed for their knowledge of strategies to avoid recurrent obstruction. For example, if fecal impaction was the cause of the obstruction, the nurse assesses the client’s ability to carry out a bowel regimen independently. For clients who have undergone surgery, the nurse evaluates their ability to function at home with the added tasks of incision care and possibly colostomy care.
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.
