Lower GI Disorders

Chapter 51, 52, 53, 54, 55

 The Small Intestine
The intestinal phase of digestion begins with the small
intestine.
Areas of the small intestine
• Duodenum
• Enzymes from pancreas break down fats/pro/CHO
• Bile digests & aids in absorption of fat
• Jejunum
• Peyer’s patches: Lymphoid tissues, monitor bacterial growth
• Ileum (terminal section)
• Vitamin B12 absorbed
Digestion Cholecystokinin (CCK) secreted in the
in the duodenum and jejunum:
• Activates gallbladder to release bile
Small • Stimulates pancreas to secrete pancreatic juice

Intestine
• Assists inhibition of digestive processes in the
stomach.

Absorption into
the body
occurs across
the villi and
microvilli.
Capillaries
carry nutrients
to the liver.
 The Large Intestine
The large intestine, as with the
remainder of the GI tract, is lined with
mucous membrane.

Areas of the large intestine

• Cecum
• Appendix
• Colon
• Ascending colon, transverse colon,
descending colon, sigmoid colon
• Rectum
 Objectives
Examine common disorders of the lower gastrointestinal
Examine system.

Identify factors that influence lower gastrointestinal

Identify disorders.

Summariz Summarize multidimensional nursing care strategies for

e clients experiencing lower gastrointestinal disorders.
Explain the differences in care strategies used for non-
Explain inflammatory, inflammatory, and infectious lower
gastrointestinal disorders.
List laboratory and diagnostic tests utilized to assess the
List lower gastrointestinal system.

Describe interprofessional collaborative care for clients with

Describe lower gastrointestinal disorders.
 Effects of Aging
 saliva
production and
Sense of taste
bone density  Cardiac sphincter Gastric mucosa
and smell
tooth loss d/t poor relaxes. atrophies.
decreases.
nutrition and
hygiene.

Occurrence of
Food stays in Peristalsis
gallstones may
stomach longer. decreases.
increase.
 Do not routinely
Teach the patient to administer a laxative;
eat high-fiber foods, Encourage the patient teach patient that
including plenty of raw to drink adequate laxative abuse
fruits and vegetables amounts of fluids, decreases abdominal
and whole-grain especially water. muscle tone and
products. contributes to an
atonic colon.

Encourage the patient

to exercise regularly,
if possible. Walking Foods to stimulate Take bulk-forming
every day is an peristalsis: warm products to provide
excellent exercise for beverages, prune juice fiber.
promoting intestinal
motility.

Patient Check the patient's

stool for amount and
frequency; oozing of
Have the patient sit on
a toilet or bedside
commode rather than

Education
soft or diarrheal stool
on a bedpan for
often indicates a fecal
elimination.
impaction.
 Bowel S/S
• Distension
obstructions • Bornorygmi
• High-pitched bowel
sounds
Non-
Mechanical • Pain
mechanical
Obstruction • Bowel sounds can become
obstruction absent
Diagnostics
Peristalsis is
The bowel is
decreased or • X-ray
blocked with
problems outside
absent because of • CT
neuromuscular
the intestine.
disturbance
TX:
• NGT
• Gastric decompression
In both obstructions, the intestinal contents accumulate at and
above the area of obstruction  distention Inability to move
contents down the intestinal tract.
 Location of Obstruction
Small Bowel Large Bowel
Obstruction Obstruction
• Abdominal pain • Lower abdominal
• Epigastric distention cramping
• N/V • Lower abdominal
distention
• Severe FE imbalances
• Minimal/no vomiting
• Metabolic Alkalosis
• Sometimes • Obstipation
• No FE imbalances
• Metabolic acidosis
• Sometimes
 Lower GI Diagnostic
Assessment
Colonoscopy: Endoscopic visualization of the colon
• Recommended for everyone >50yo
• Sooner if any family hx/bowel issues
• Gold standard for detecting colon cancer
• Can complete biopsies, remove polyps, or visualize the source of
GI bleeding
Pre-op:
• Bowel Prep: GoLytely, enemas, etc.
• Clear liquid diet pre-procedure no red, purple, or orange liquids

Post-op:
• Air is injected into the colon for better visualization Gas post-
procedure
 Small growths covered with
What is a Polyp? mucosa and attached to the
intestine’s surface.

• Most are benign but may

become malignant.
• They are ASYMPTOMATIC.
• Discovered during routine
colonoscopies.
• May cause rectal bleeding,
obstruction, or intussusception.
• Must be monitored through
frequent colonoscopies
• TX: Polypectomy
• May be removed
How does this occur?
 Nursing Care
Nursing care focuses on patient education. Instruct the
patient about:
• The nature of the polyp
• Signs and symptoms to report to the health care provider
• The need for regular, routine monitoring or screening
• If had polypectomy, follow-up sigmoidoscopic or colonoscopy exams are needed

Nursing care of the patient after a polypectomy of the

colorectal area includes:
• Monitoring for abdominal distention and pain, rectal bleeding, mucopurulent
drainage from the rectum, and fever.
• A small amount of blood might appear in the stool after a polypectomy, but this
should be temporary.
Colorectal Cancer
Risk factors include:
• 50 years
• However, increased incidence is found in adults ~45yo
• Genetic predisposition
• Family HX Cancer
• Obesity
• Smoking
• Heavy alcohol use
• Physical inactivity

Predisposing diseases:
Chemotherapy
• Familial adenomatous polyposis (FAP)
• Crohn’s disease
• Ulcerative colitis
Colectomy
Ostomies
Ostomy care POD1:
• Stoma will be edematous and may have small amount
of bleeding.

Monitor for post-op complications:

• Excessive bleeding.
• Stoma dark in color or blanched.
• Drying of stoma.
• Signs of infection.

May shrink 2-3 weeks post surgery.

May take 4-6 weeks to determine stoma
size.
 Colostomy Assessment
Assess the
condition of the
stoma Strict attention to
Assess peristomal
skincare/peristomal
• Color skin
• Condition of the stoma skin assessment
• Assess for
mucocutaneous
separation

Be attentive to the
Monitor the amount Be professional;
client’s
and type of effluent show acceptance
psychosocial needs

Address client
Attend to odor
participation in
control
ostomy care
 Ostomy Pouches and Accessories

Use an ostomy guide to cut

the opening on the wafer
1/16 to 1/8 larger than the
stoma.

We want to fit the

appliances around the
stoma w/out touching the
stoma or exposing the
surrounding skin.
Gastric Surgeries Nursing
Considerations
Keep pt NPO

NGT suctioning for 2-3 days

Keep NGT patent, pt in semi-fowlers

Observe NGT drainage consistency and color

• Green/yellow normal, red is not

Ambulate the patient ASAP

Monitor surgical site for infection- No heavy lifting

Assess bowel sounds every shift

• Bowel sounds + clamp tube and assess for complications (n/v, pain, etc.) If there are no
complications, MD may order a clear liquid diet.
 Patients undergoing a colon resection by open
approach are typically hospitalized for 2 to 3
days or longer, depending on the age of patient
and complications or concurrent health
problems.

Care Collaborate with CM to help patients and

families cope with an immediate postoperative

Coordinatio
phase of recovery.

n and
After hospitalization for surgery, the patient is
usually managed at home.

Transition Radiation therapy or chemotherapy is typically

administered on an ambulatory care basis.

Managemen For the patient with advanced cancer, hospice

t care may be an option
rritable Bowel Syndrome
Most common digestive disorder
• Functional GI disorder that causes chronic or
recurrent diarrhea, constipation, and/or
abdominal pain and bloating

S/S
• Cramps
• Abdominal pain
• Diarrhea
• Constipation
• Bloating

Classifications:
• IBS-D (diarrhea)
• IBS-C (constipation)
• IBS-A (alternating diarrhea/constipation)
• IBS-M (mix of diarrhea/constipation)
Health teaching-Diet Modifications
• 30-40 grams of fiber daily
• Promote normal bowel function
• Avoid GI stimulants, caffeine, alcohol, milk and milk products

Drug therapy
• Symptom specific
• Adhere to medication regime if prescribed
• Taper medications such as corticosteroids are used to decrease
inflammation.

Stress reduction
• Relaxation
• Meditation
• Yoga
For patients with increased intestinal bacterial
overgrowth
• Probiotics effective for reducing bacteria and successfully
alleviating GI symptoms of IBS
• Peppermint oil capsules may be effective in reducing symptoms
for patients with IBS
 Hernias
A hernia is a weakness in the abdominal muscle wall
through which a segment of the bowel or other
abdominal structure protrudes.

The doctor may be able to reduce the hernia.

Some hernias are irreducible (incarcerated)  surgical

intervention is needed.

Strangulated Hernia
Hemorrhoids
Unnaturally swollen or distended veins in the
anorectal region

Distended veins eventually separate from smooth

muscle

The result is prolapsed of the hemorrhoidal vessels.

Types:
Internal hemorrhoids

External hemorrhoids

Prolapsed hemorrhoids: thrombosed

or inflamed, or they can bleed
Health
Promotion &
Maintenance

• Increasing fiber in the diet,

• Eat more whole grains and raw
vegetables and fruits.
• Encourage patients to drink plenty
of water unless contraindicated
• Remind the patient to avoid
straining at stool.
• Remind him or her to exercise
regularly with a gradual buildup in
intensity.
• Maintaining a healthy weight helps
prevent hemorrhoids.
 Nursing Interventions for
Hemorrhoids
Reduce symptoms
Local treatment Cold packs applied
with minimal Tepid sitz baths
and NUTRITION to the anorectal
discomfort, cost, three or four times
therapy (high region for a few
and time lost from per day
fiber/fluids) minutes
usual activities

Dibucaine
(Nupercainal)
ointment and
Topical anesthetics, Cleanse anal area
similar products are Avoid sitting for
such as lidocaine with moistened
available OTC long periods
(Xylocaine) cleansing tissues
applied for mild-to-
moderate pain and
itching

Remove
symptomatic
hemorrhoids
(hemorrhoidectomy
)
Anal fissure: A tear
in the anal lining

Smaller fissures occur with straining to have

a stool, such as with diarrhea or
constipation.
It can take up to 6 weeks to heal on its own

Management of an acute fissure is usually

aimed at local pain relief and softening of
stools to reduce trauma to the area.
 Anorectal Abscess
Cause:
• Obstruction of the ducts of glands in the anorectal region.
• Feces, foreign bodies, or trauma can be the cause of the obstruction and stasis,

S/S:
• Rectal pain is often the first symptom.
• Local swelling, redness, and tenderness are present within a few days after the
onset of pain.
• Chronic: discharge, bleeding, and pruritus (itching) may exist.
• Fever
Management:
• I&D
• The physician can often excise (surgically remove) simple perianal and
ischiorectal abscesses using a local anesthetic.
 Peritonitis
Acute inflammation and infection of the visceral/parietal peritoneum and the endothelial
lining of the abdominal cavity

Causes
• Contamination of the peritoneal cavity by
bacteria or chemicals.
• Bacteria enter the peritoneum by
perforation
• Appendicitis
• Diverticulitis
• PUD
• External penetrating wound
• a gangrenous gallbladder
• Bowel obstruction
• Ascending infection through the genital
tract.
Less common causes include
perforating tumors, leakage or
contamination during surgery*
 Clinical manifestations
Abdominal
Rigid, pain, or Nausea,
Distended Diminishing
boardlike referred to the anorexia,
abdomen bowel sounds
abdomen shoulder or vomiting
chest)

Dehydration
Inability to Rebound Free air, excess
Tachycardia, from high
pass flatus or tenderness in fluid in
fever fever (poor
feces the abdomen abdomen
skin turgor)

Possible
Decreased compromise
Hiccups
urine output in respiratory
status
 Assess VS
frequently

Catheters
may be left
in place to Monitor
drain the LOC
abdomen
post-op

Peritonitis
The
surgeon will
Treatment Broad
irrigate the spectrum
peritoneum abx
with abx

Abdominal
surgery may be
needed to Monitor
identify and
repair the cause oxygenati
of the peritonitis on
• Focus on treating
the cause
Appendicitis
• Most common cause of right lower quadrant
pain
• Inflammation occurs when the lumen
(opening) is blocked

RLQ pain Abdominal pain N/V

Cramping pain
in the
epigastric or Anorexia Elevated WBC
periumbilical
area
 Appendicitis Treatment
Do not
Do not
apply heat
administer
to the
enemas
abdomen
Patient may have an
Keep
patient NPO
Administer
IV fluids
appendectomy
• Open vs. lap
Administer • 3-5 days abx
Monitor
electrolytes
pain • Nurses' role: prevent post-op
medication complications.
Administer
antibiotics Rupture
if Peritonitis
prescribed
Chronic Inflammatory Bowel
Disease
Ulcerative Colitis (Limited to the colon) and
Chron’s Disease (Can occur anywhere
between mouth and anus)

The approach to each

patient is individualized
• Encourage patients to self-
manage their condition by
learning about the illness,
treatment, drugs, and
complications
• Higher risk for cancer
Feature Ulcerative Chron’s
colitis

Location Begins at Often in

rectum and ileum, but
moves up occurs in
patches
throughout
the bowel
Etiology Unknown Unknown

Age of 10-25 15-40y

Incidence
# stool 10-20 5-6 soft
liquid/bloody loose

Need for SX Infrequent Frequent

Associated Complications
Treatment
Steroid infusions

Anti-diarrheals (Used sparingly d/t toxic megacolon)

Immunomodulators

TPN

Rest

Surgery
• UC may need surgery for disease

Pain management
 Titration of
TPN and
TPN Discontinuati
on of TPN
serial Blood
glucose
should be monitoring is
done
necessary
• Used when a patient’s GI tract is non- gradually to
avoid
during this
functioning rebound time
• It can be TPN or PPN hypoglycemia
• Used in clients who need
increased nutritional support
• Done through an IV line, generally a
central catheter (TPN), but some
types can be given Peripherally (PPN)
• *Never use the TPN IV line to deliver
any other medications*
• Monitor Labs d/t potential electrolyte
imbalances/Glucose issues
Gastrointestinal
bleed
Bright red blood indicates a lower bleed,
possibly hemorrhoids or, in some cases,
cancer.

Interventions
Labs: CBC, hemoglobin, and hematocrit.

Nursing:
Occult blood

Treatment
Admin blood transfusions
UGI bleed TX Protonix
if needed
Diverticula: pouchlike herniations
of the mucosa through the muscular
wall of any part of the gut, but most
commonly the colon
Bacteria in diverticula 
 Blood supply 
Diverticulitis
• Patient typically asymptomatic
• Unless pain or bleeding
develops the condition may go
unnoticed.
Assessment:
• Hx of constipation
• Intermittent than progressive to
localized abdominal pain in
LLQ
• Hx of low-grade fever
• Nausea
 Diverticulitis Education
Diet:
• High-fiber diet: (25-35 grams of fiber per day)
• Diet high in cellulose and hemicellulose fibers
• wheat bran
• whole-grain bread
• Cereals
• Metamucil
• Fluids

AVOID: (During inflammatory Process)

• No alcohol, seeds, nuts, corn, popcorn, cucumbers,
tomatoes, figs, strawberries
 Malabsorpti
on
Syndrome
Causes
• Inflammation & Intrinsic
disease:
• Vitamin B12 Deficiency
• Celiac DX
• SIBO
• Infections
• Chemo/Radiation
• Alcohol use disorder
• Injury to the lining of the
intestine.
 S/S: Quantitative fecal fat analysis is
elevated
Lactose tolerance test Hydrogen
breath test can also be performed
to detect this problem.

Steatorrhea Unintentional Bloating and Schilling test

(fatty stool) weight loss flatus
Ultrasonography

Anemia (with
X-rays
Decreased Easy bruising iron and folic
libido (pupura) acid or B12
deficiencies) CT scan

Bone pain Edema

Diagnostics
 Disorders of the Liver
Liver failure (hepatic coma)
• Life threatening

Cirrhosis Nursing
• Severe scarring Educations for
Hepatitis B
Hepatitis
• Inflammation • DO NOT share needles,
razors or toothbrushes
Liver abscess
with anyone
• result from bacterial, fungal, or parasitic • Take the HBV
infection • Monitor labs
Trauma
• Use protection during
Liver transplant sexual intercourse
• cure for end-stage liver disease or liver
failure
Liver cancer
• rare
 • Widespread inflammation and infection of the liver
Hepatitis cells
• Viruses cause most cases of hepatitis.
• Drug or alcohol use can also cause hepatitis
 Widespread

Cirrhosis scarred bands

of connective
tissue that
change the
liver’s
anatomy

Nursing Considerations Cirrhosis

• Lab monitoring
• Monitor Neuro status
• Hepatic encephalopathy
• Nutrition support
• Medication therapy/education
• Pain management
 Chapt
er 54
Care of
Patients with
Problems of the
Biliary System
and Pancreas
Disorders of the
Gallbladder
Cholecystitis
• TX: Surgery

Cholelithiasis
• Formation of gallstones

Common bile duct obstruction

• → cholecystitis

Cancer of the gallbladder

 Cholecystitis
Inflammation of the gallbladder wall

• It can be Acute or chronic

• It is almost always associated with cholelithiasis, or gallstones, which lodge in the
cystic duct  obstruction.
 • Severe pain in
your upper
right or center
abdomen.
• Pain that
spreads to
your right
shoulder or
Cholecystitis back. Diagnostic Assessments
• Rebound
S/S • Ultrasonography
abdominal • HIDA Scan
tenderness
• ERCP
• Vomiting.
• MRCP
• Fever
• Dyspepsia Priority concerns
• Weight loss due to pain, nausea,
and inflammation
Risk Factors:

• Fatty foods
• Obese
• Fertile
• Over forty
• Low fiber diet
• Diabetes
 Slowly developing symptoms and may not
Chronic seek medical treatment until late symptoms

Cholecysti Yellowing of the sclera (icterus) and oral

tis mucous membranes may also be present.

Steatorrhea (fatty stools) occurs because fat

absorption is decreased due to the lack of bile.

Bile is needed for the absorption of fats and

Chronic fat-soluble vitamins in the intestine.
inflammation
leads to Temperature of 99° to 102° F (37.2° to 38.9°
gallbladder C), tachycardia, and dehydration from fever
wall and vomiting.
thickening   nutrition intake d/t pain or symptoms that
Non- arise when food is eaten.
functional
 Treatment
Promoting Nutrition
• High fiber, low-fat diet
• Small, frequent meals

Nonsurgical Management
• Manage Pain
• Drug Therapy
• Lithotripsy

Surgical Management
• Lap cholecystectomy:
• Minimally invasive
• Performed far more than the traditional open approach
• Complications are not common.
• Patient recovery is quicker.
• Postoperative pain is less severe.
Pancreatitis
Acute Pancreatitis

Causes
• Obstruction

Treatment includes
• Pain management
• IV fluids
• Monitoring electrolytes
• Patient remains NPO
• NGT for severely ill
 S/S Acute Pancreatitis
Severe Acute pain d/t pancreatic enzyme leakage
and inflammation
• Mid-epigastric or LUQ
• Radiates to shoulder

Elevated Pancreatic Enzymes

Nausea/Vomiting

Weight loss

Unable to eat without excruciating pain

 Causes

• Alcoholism

Chronic •
•
•
Hx of biliary tract disease
Idiopathic/hereditary

Pancreat
Autoimmune

S/S

itis •
•
Intense and pain/tenderness
Ascites
• Resp compromise
• Steatorrhea/clay-colored stools
• Weight loss
• Jaundice
• Dark urine
• 3 p’s of DM
Chronic Pancreatitis Treatment
Dietary control

• No alcohol

Control Diabetes

Take pancreatic enzymes

Patient and family Teaching

 Surgical Management of Biliary
Disorders
• Cholecystectomy
• Lap vs. open Gallbladder removal
• ERCP
• Minimally invasive, removes gallstones
• Choledochotomy
• Surgical incision of CBD
• Hepatectomy
• Radical Pancreatectomy, aka Pancreaticoduodenectomy,
aka Whipple Pancreatectomy
• Partial (Tumor <3cm)
Conditions of Under &
Overnutrition
Obesity
• The condition of being overly fat, not necessarily overweight
• Calculated body mass index (BMI) as diagnosis
• BMI >30 obese

Anorexia nervosa
• Self-imposed starvation

Bulimia
• Binge syndrome
 Nursing Considerations

Remove
Minimize
emesis basins, Give an
distractions Provide mouth
bedpans, etc antiemetic
during care
from the prior to meals
mealtimes
environment
Keep a journal
Malnutrition
Attend all or diary to
Work with an prevention by
therapy document the
RD supplementati
sessions progression of
on
recovery