Diarrhea, Constipation

Diarrhea: Definition: • Passage of several watery, unformed stools due to rapid mass movement. • Comparison with the usual frequency and consistency is a must. Types: • Can be acute or chronic (according to duration) • Acute can due to toxic, dietary or infectious cause. (according to cause) Causes: • Common cause of infectious diarrhea: shigella, salmonella, staphylococci. Usually comes from meat, milk, dried eggs. • Neurogenic diarrhea: this is due to nervous tension which stimulates PNS=Increased motility and mucus production. Effects: • Prolonged diarrhea causes Fluid and electrolyte imbalance =decreased body weight and fatigue Character of stools and its probable indications: • Bloody: desentery, ulcer • Gaseous, rancid and pungent: malabsorption • Large, soft stools with food particles= decreased HCL acid • Mucus: colitis, cancer of the colon Stool C/S: • Use sterile bottle to get specimen. • If possible, should be obtained before antibiotic therapy. It should not contain poil, barium, bismuth compounds Assess for: • ACF of stools (amount, character and frequency\) • Weight • Bowel sounds • Skin turgor • Fever • thirst • less frequent urination • dry skin • fatigue • light-headedness • dark-colored urine Nursing Management: • Increase OFI. Use juices, broths or soups that contain electrolytes. • Oral rehydration solutions such as pedialyte maybe used especially for children, • Avoid foods that contain, caffeine, milk products, high fiber and oily foods. Client Education:

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Do not drink tap water or use it to brush your teeth. Do not drink unpasteurized milk or dairy products. Do not use ice made from tap water. Avoid all raw fruits and vegetables, including lettuce and fruit salads, unless they can be peeled and you peel them yourself. Do not eat raw or rare meat and fish. Do not eat meat or shellfish that is not hot when served. Do not eat food from street vendors.

Constipation: Definition: • Passage of dry, hard stools due to abnormal retention of feces in the large intestine or delay/failure to defecate. Location: • It can be colonic or rectal Causes: The most common cause of constipation is a diet low in fiber found in: • vegetables, • fruits, • and whole grains • Not enough liquids • Lack of exercise • Medications • Irritable bowel syndrome • Changes in life or routine such as pregnancy, older age, and travel • Abuse of laxatives • Ignoring the urge to have a bowel movement • Specific diseases such as multiple sclerosis and lupus • Problems with the colon and rectum • Problems with intestinal function. Important AnaPhysio Concepts: • Diaphragm is the strongest muscle that aides in the fecal-expulsion mechanism. It can be weakened by pulmonary disorders. • Large rectus muscle which creates increased intra-abdominal pressure that aides in the fecal-expulsion mechanism can be weakened by pregnancy, ascites and abdominal distention. • Levator ani muscles in the pelvic floor which also aids in the expulsion of feces can be weakened by thepressureof the fetal head during prenancy and child birth. Asses for: • ACF of stools • Pain in the sacrum, buttocks, thighs and hips. • Use of cathartics and laxatives. Client Education: • Increase OFI • High fiber diet

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Exercise

Fecal Incontinence: Irritable Bowel Syndrome: Definition: • Is a CHRONIC GI disorder characterized by the presence of chronic or recurrent diarrhea, constipation, abdominal pain and bloating. • Also called as spastic colon, nervous colon or mucous colon. • Due to the impairment of motor or sensory function of GI. Etiology and risk factors: • Exact cause is unknown. • Risk Factors include: a. diverticulitis b. ingestion of foods with caffeine and other gastric irritants c. lactose intolerance d. stress e. history of panic disorders, anxiety disorders and major depression S/Sx: • abdominal pain (LLQ) and cramps RELIEVED by defecation or associated with changes in stool’s ACF • abdominal distention • sensation of incomplete evacuation of stool • Presence of mucus in stool Assessment: • Normal weight and bowel sounds • Diffused tenderness upon palpation. Dx: • Normal CBC • Normal Stool occult blood • Normal ESR • Barium enema, Sigmoidoscopy and colonoscopy: colonic spasm is common during this procedure but is not definitive. Interventions: • Health Teaching: a. Identify foods that upset one’s stomach and avoid them. b. Limit caffeine and alcohol intake c. Milk and milk products should be avoided if lactose intolerance is detected. d. Regular intake of high fiber foods (30 to 40 g of fiber/day) e. Stress management

f. Chew foods slowly • a.

Drugs: Bulk forming laxatives (Metamucil): for constipation-predominant IBS

b. Anti-diarrheal agents (Lomotil and Immodium) : for diarrheal-predominant IBS

c. Anticholinergics or Anti-spasmodic(Bentyl): for pain-predominant IBS Intestinal Obstruction: • Partial or complete obstruction in the lower GI tract (ileum is the most common site) • Types:

a. Mechanical: the bowel is physically obstructed by either intestinal contents, inflammation, tumor, hernias, strictures.

b. Non-mechanical: due to neuromuscular disturbances. also known as paralytic ileus. Pathophysiology: Mechanical or non mechanical obstruction ↓ Intestinal contents( ingested foods, fluids gastic, pancreatic and biliary secretions) accumulates at and above the area ↓ ↓ ↓ Intestinal absorption Increased peristalsis as compensation ↓ Increased secretion ↓ Abdominal distention and pain ↓ Bacterial Peritonitis ↓ Edema of the bowel and peritoneum ↓ Decreased fluid and electrolytes in the Intravascular space ↓ Mild to Severe Hypovolemia ↓ Renal Insufficiency and even Death Etiology: Mechanical Obstruction: • Adhesions (most common 45 to 65% of cases) • Tumors • Hernias • Fecal impactions • Strictures • Intussusception • Volvulus

• Fibrosis • Vascular disorders Non-mechanical: • Surgery • MI • Rib fractures • Pneumonia • Peritonitis Hx: • Past or recent abdominal surgery • History of IBD • Hernias • Trauma • Cancer • Peritonitis Assessment: • Mid-abdominal pain or cramping, sporadic in quality • If strangulation is present, the pain is more steady and localized. • Vomiting. Vomitus may contain bile and mucus and maybe orange brown in color and foul smelling. • Obstipation: no passage of stool may occur with complete obstruction Small Intestine Large-intestine Obstruction obstruction Abdominal pain accompanied by peristaltic waves visible in upper and middle abdomen.

Intermittent cramping

abdominal

Upper or epigastric abdominal distention

Lower distention

abdominal

Profuse Nausea and vomiting

Minimal vomiting

Obstipation

Obstipation or ribbonlike stools

Sever fluid and electrolyte imbalances

No major imbalance

Metabolic alkalosis

Metabolic acidosis

F

and

E

Laboratory and diagnostic exams: • WBC maybe normal except if strangulation is present. • H and H, creatinine, BUN are often elevated indicating dehydration. • Serum sodium, potassium and chloride are reduced. • ABG

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X-ray Barium enema, colonoscopy or sigmoidocscopy except when perforation is already\ been determined • CT scan. • Explorative Laparotomy Interventions: • NGT (nasogasrtic tube for evacuation of gastric contents) • NIT (nasointestinal tube for evacuation of • NPO • Semi-fowler’s position with frequent position changes from side to side. • Fluids and Electrolyte replacement • Ice chips • Morphine for pain (SE: vomiting) • IV antiobiotics

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Inflammatory Bowel Disease: Ulcerative Colitis: • Inflammation of the mucosal lining of the colon making it prone to ulcer. • It can result to loose stools with blood and mucus, poor absorption of nutrients and thickening of the colon wall Etiology and risk factor: • Unknown • Genetic predisposition Hx: • Family history • stress • Diet • Elimination pattern • ACF of stools • Weight S/Sx: • Abdominal pain • Bloody diarrhea • Tenesmus (uncontrollable straining) • Abdominal distention • Rebound tenderness if peritonitis is present • Stool C/S Laboratory and diagnostic exam: • H and H are low • WBC and ESR are high • Na, K and Cl are low • Barium enema with air contrast Interventions: • Diarrheal management • Salicylate compounds: Sulfasalazine inhibits prostaglandin synthesis • Corticosteroids • Anti-diarrheal drugs such as motilium • Chew foods thoroughly

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NPO for severe cases TPN Ostomy care Be cautious of high fiber foods Bedrest Empty pouch when it is one half full

Surgical Interventions: • Proctocolectomy with permanent ileostomy Crohn’s Disease: Definition: • Idiopathic inflammatory disease disease of the small intestine, the colon or both. It is chronic and nonspecific. • It involves all layers of the bowel but most commonly the ileum • It is a slowly progressive and recurrent disease with predominant involvement of the regions of bowel with normal sections between them. • Eventually, fissures, ulcerations and bowel thickening occurs resulting to diarrhea and malabsorption of vital events. Etiology: • Genetics • Mycobacterium paratubercolosis Assessment: • Fever • Abdominal pain • Loose stools • Weight loss • ACF of stools (steatorrhea) • Abdominal tenderness • Guarded movement • Palpable mass in the RLQ • High pitched, rushing bowel sounds Laboratory and diagnostic exam: • Decreased H and H if bleeding is present • Decreased Serum levels of folic acid and B12 • Decreased serum albumin levels • ESR and WBC elevated • X-rays • Barium enema Interventions: • Diarrheal management • Salicylate compounds: Sulfasalazine inhibits prostaglandin synthesis • Corticosteroids • Anti-diarrheal drugs such as motilium • Chew foods thoroughly • NPO for severe cases • TPN

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Ostomy care Be cautious of high fiber foods Bedrest Empty pouch when it is one half full

Client Education: • Skin care in ostomy areas • B12 supplements • Rest and stress management • Low residue and high calorie diet Colorectal Cancer: Definition: • Cancer of the colon and rectum (CRC) • 95 percent are adenocarcinomas • Abnormal proliferation of colonic mucosa starts as visible polyps in the colon that turns into malignant tumors • 70 % of the polyps in the colon occurs in the rectosigmoidal region. • Colorectalcancer may metastasize through direct extension (tisuue to tissue) and through the circulatory and lymphatic system. • Liver is the most common site of metastasis (15 to 30 % of cases). • It can also spread in the brain, lungs, bones and adrenal glands. Etiology and risk factors: • Genetics : first degree relative have a threefold chance in acquiring the disease • Cause in unkown • 95 percent of cases are 50 years old and above. • ↑ fat and ↓fiber diet • obesity • IBD and Crohn’s disease • Eating foods such as: a. Red meat b. Animal meat c. Fatty foods d. Friend meats and fish e. Refined carbohydrates Health Promotion and prevention: • Diet modification • Regular exercise • Daily vitamins, HRT, oral contraceptives • Aspirin Hx: • Family history of CRC, IBD, Crohn’s, disease • Diet • Stool Assessment: • Ascending colon:

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✔ Occult blood in stool ✔ Anemia ✔ Anorexia and weight loss ✔ Pain above umbilicus ✔ Palpable mass in the RLQ Descending colon: Rectal bleeding Change in bowel habits Constipation or diarrhea Pencil or ribbon shaped stools Tenesmus Sensation of incomplete bowel emptying

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Duke’s Classification of CRC: Stage A: confined to bowel mucosa (80-90% 5 years survival rate) ✔ Stage B: Invading muscle wall ✔ Stage C: lymph node involvement ✔ Stage D; metastasis or locally unresectable tumor (less than % 5 years survival rate) Guidelines for early detection of CRC: • Digital-rectal exam yearly after age 40 • FOBT yearly after age 50 • Proctosigmoidoscopy every 5 years after age 50 following 2 negative result of yearly examination Collaborative Management/ Interventions: • Surgery: ✔ Hemicolectomy: for ascending and transverse colon caner ✔ Abdomino-perineal resection (APR): for recto-sigmoid cancer ➢ There are two incisions: 1. Lower abdomen incision to remove the sigmoid.

2. Perineal incision: to remove the rectums

➢ T-binder is used to secure perineal ➢

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dressing Necessitates permanent colostomy

Chemotherapy: Fluorouracil-5 Radiotherapy Colonic surgery:

Laboratory and diagnostic exams: • FOBT Fecal Occult Blood Test (Guiac stool exam) • CEA: Carcinoembryonic antigen: may be elevated in 70 % of CRC patients but also present in smokers and other malignancies. • CT scan • X-ray

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Double-contrast barium enema (air and barium) Sigmoidoscopy and colonoscopy (definitive test for CRC) Liver scan may located distant sites for liver metastasis. Psychosocial support