Medical surgical nursing

1. Prepared by Tesfa D.(B.Sc.)
Gastrointestinal Disorder
Lecture Note

2. Chronic Inflammatory Bowel Disease
(IBD)
 It is used to designate two chronic
inflammatory GI disorders:
1) Regional enteritis (Crohn's Disease)
2) Ulcerative Colitis:-It is very serious
and high mortality rate.
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3. Regional enteritis (Crohn's Disease)
 Epidemiology;
 commonly occurs in adolescents or
young adults.
 It is more common in older women
population (50 and 80).
 Most common affected areas are the
distal ileum and colon.
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4. Cont…d
 Pathophysiologic feature of the lesion:
 Subacute and chronic inflammation that
extends through all layers.
 Lesions are not in continuous contact with
one another and are separated by normal
tissue.
 In advanced cases, the intestinal mucosa has
a cobblestone appearance.
 It is characterized by periods of
remissions and exacerbations.
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5. Cont…d
Clinical Manifestations
Insidious onset
 Prominent lower right quadrant
abdominal pain (crampy).
 Diarrhea
 Weight loss
 Malnutrition
 Secondary anemia
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6. Cont…d
 Intra-abdominal and anal abscesses.
 Ulcers in the intestinal membrane.
 Fever
 Leukocytosis
 Fistulas
 Fissures
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7. Cont…d
 Chronic symptoms include;
 diarrhea,
 abdominal pain
 steatorrhea
 anorexia
 weight loss
 nutritional deficiencies
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8. Cont…d
 Symptoms extend beyond the GI
tract;
Joint involvement (e.g, arthritis)
Skin lesions (e.g, erythema
nodosum)
Ocular disorders (e.g,
conjunctivitis)
Oral ulcers. 12/13/2019 8

9. Cont…d
Assessment and Diagnostic Findings
 Proctosigmoidoscopic examination (to
determine the affected area).
 Stool examination ( for identification of
blood and abnormal fat).
 Barium study on X-ray (most conclusive).
 Endoscopy
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10. Cont…d
 Intestinal biopsy
 CT scan ( for bowel thickness and fistula
formation identification)
 CBC
 ESR
 Albumin and protein levels
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11. Cont…d
Complications
 Intestinal obstruction/stricture formation.
 Perianal disease.
 Fluid and electrolyte imbalances.
 Malnutrition.
 Fistula.
 Abscess formation.
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12. Ulcerative Colitis
 It is a recurrent ulcerative & inflammatory disease
of the mucosal layer of the colon &rectum.
 It affects superficial mucosa of the colon & is
characterized by multiple ulcerations & diffuse
inflammations which end up with shading of
colonic epithelium.
 The lesions are contiguous, occurring one after the
other.
 The disease process usually begins in the rectum
and spreads proximally to involve the entire colon.
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13. Cont…d
Etiology – unknown (may be
mycobacterium), and an auto
immune response to certain
predisposing factors.
 Predisposing factors:-
 Anxiety
 Tobacco
 Radiation
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14. Cont…d
C/M
 Diarrhea (10 t0 20 liquid stools daily)
 Abdominal pain
 Intermittent tenesmus
 Rectal bleeding
 Hypocalcemia
 Anemia
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15. Cont…d
 Anorexia
 Weight loss
 Fever
 Vomiting
 Dehydration
 Rebound tenderness may occur in the
right lower quadrant.
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16. Cont…d
 Extraintestinal symptoms;
Skin lesions (eg, erythema
nodosum)
Eye lesions (eg, uveitis)
Joint abnormalities (eg, arthritis),
Liver disease.
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17. Cont…d
Diagnostic evaluation
 Careful steel exam;
 to r/o amoeba (dysentry)
 is positive for blood
 CBC
 Low hgb & Hct level
 Elevated WBC
 Sigmoidoscopy & barium enema
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18. Cont…d
 CT scanning
 Magnetic resonance imaging
 Ultrasound
 Abdominal x-ray
 Barium enema
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19. Cont…d
Complication
 Perforation
 Hemorrhage
 Malignant neoplasm
 Toxic mega colon
 Osteoporosis
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20. Medical Management of Chronic
Inflammatory Bowel Disease
 Management depends on the disease
location, severity, and complications.
The goal of the management is: -
1.To reduce the inflammation
2.To suppress in appropriate immune
response
3.To provide rest for the diseased bowel
4.To improve quality of life and
5.To prevent complications
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21. Cont…d
Nutritional therapy
 Advice to have a low residual, high protein,
high-calorie diet with supplemental vitamin
therapy & iron supplement.
 Advice to take oral fluids/ IV fluids as
tolerated.
 Advice to avoid any food (milk) which
exacerbate diarrhea.
 Advice to avoid smoking and cold foods.
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22. Cont…d
Pharmacologic therapy
 Sedatives
 Anti-diarrheal/ anti peristaltic
 Amino salicylate (eg, sulfasalazine)
 Corticosteroids (eg, prednisone)
 Antibiotics (sulfapyridine, metronidazole)
 Immunomodulators (eg, azathioprene, 6-
mercaptopurine, methotrexate, cyclosporin)
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23. Cont…d
Surgical management
 The surgical procedure is termed as
proctocolectomy with ileostomy.
 Indication includes;
Profuse bleeding
Perforation/Stricture forming ulcers.
Development of cancer
Lake of improvement with medical
managements.
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24. Cont…d
Nursing management
 Education about diet, medications,
about management of the ostomy and
referral to support groups.
 Careful monitoring, parenteral
nutrition, fluid replacement.
 Emotional support if surgery is done.
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25. Comparison between UC and RE
See Medical-Surgical Nursing, 10th ed -
Brunner & Suddarth, chapter 38, page
1041, table 38-4,
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26. Intestinal obstruction
 Intestinal obstruction exists when
blockage prevents the normal flow of
intestinal contents through the intestinal
tract.
 It can be classified as the following:-
A) Mechanical obstruction Vs Functional
B) Small bowel Obstruction Vs Large
bowel
C) Partial Obstruction Vs Complete12/13/2019 26

27. Cont…d
Causes of Intestinal Obstructions
1) Causes of Small bowel
obstruction
 Adhesion (the most common)
 Surgery
 Intestinal Tuberculosis
 Inflammatory Condition of
intestine. 12/13/2019 27

28. Cont…d
 Paralytic ileus
 Hernia
 Gallstones ileus
 Tumor
 Ascaris bolus
 Intusscusption (It is the small bowel
telescopes, as if it were swallowing itself
by invagination. It is the commonest
problem in infants.)
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29. Intusscusption
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30. Cont…d
C/M of SBO
 Sudden Colicky pain intermittent with
10 -20 minute Interval.
 Initial Vomiting
 Normal Stool may be passed or
bloody.
 Restless, dehydration &cry
 Distention is late
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31. Cont…d
2) Cause of large bowel Obstruction
 Colorectal Cancer
 Adhesion
 Paralytic ileus
 Inflammatory bowel disease
 Volvulus (It is twisting of a mobile loop
bowel on its mesentery. It occurs mostly
in sigmoid colon but it can affect small
intestine & caecum.)
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32. Volvulus
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33. Cont…d
Cardinal S/S of large bowel Obstruction
 Colicky lower abdominal pain
 Absolute Constipation ( Flatus & Feces
)
 Gross abdominal distention
 Nausea and Vomiting
 Abdominal x-ray reveals grossly
distended 2 limbs of sigmoid colon often
with fluid - air level. 12/13/2019 33

34. Comparison of obstruction
SBO LBO
 Abdominal
crampy
 Vomiting early
S/S
 Constipation late
sign
 Abdominal
distention
 Abdominal
crampy
 Constipation is
early S/S
 Grossly distended
abdomen
 Fecal vomiting12/13/2019 34

35. Cont..d
SBO… LBO…
 Diagnostic method-
Hx & P/E.
 Abdominal X-ray
indicates abnormal
quantities of gas &/or
air in the bowel.
 Decompression of the
bowel through NG
tube.
 Diagnostic method-Hx &
P/E.
 Abdominal x-rays reveals
abnormally distended
colon.
 Colonoscopy may be
performed to untwist &
decompress the bowel in
high colon obstruction.
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36. Cont…d
SBO… LBO…
 IV fluid ( N/S or R/L )
administered to replace
electrolyte and water.
 Surgical Intervention is
needed.
 More severe because
most of the GI content
are absorbed in this
part.
 In lower bowel
obstruction rectal tube
may be used for
decompression.
 Surgical Intervention if
it is caused by tumor
 Iv fluid administration.
 Minor unless necrosis
occurred. 12/13/2019 36

37. Cont…d
Diagnostic evaluation of Intestinal
Obstruction
1) Hx
2) P/E - pt is acutely sick looking
 V/S: - B/P - decrease due to fluid loss &
sepsis
 PR:- Tachycardia
 To :-Increases if there is complication
 HEENT :- dry buccal mucosa12/13/2019 37

38. Cont…d
 Abdomen
 Distended
 Mild tenderness on palpation
 Visible loop but not always
 Tympanic on percussion
 Bowel sound may be absent or
increase
 Empty rectum or hard stool
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39. Cont…d
 CBC
 Hgb
 V/A
 Abdominal x-ray
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40. Cont…d
Medical Management:
A) General Management
 Keep the patient NPO
 NG tube should be inserted for small bowel
obstruction to aspirate intestinal content.
 Secure IV line ( Normal Saline or ringer
Lactate )
 Triple antibiotic ( Ampicillin,
Gentamycin,& CAF )
 Sedation
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41. Cont…d
B) Specific RX
 Sigmoid Volvulus :-
 Rectal tube is inserted for deflation but
contraindicated if gangrenous.
 Laparatomy.
1) If loop is viable= de-rotation
2) If gangrenous= resection &
Colostomy
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42. Hernias
 Def.:-It is a protrusion of bowel through a
weak point in the musculature of the
anterior abdominal wall or an existing
opening.
 Etiology
 Powerful muscular effort or strain.
 Weakness or defect to the wall of
abdominal cavity.
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43. Cont…d
 Predisposing factors:-
 Constipation
 Ascites
 Previous abdominal surgery
 Lifting heavy load
 Chronic Cough
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44. Classifications of hernias
1. Based on Sites of Hernias :
I) Inguinal Hernia
 The protrusion of bowel through the
weak point in the inguinal canal which
contains the spermatic cord in the male
& the round ligament in the female.
 It occurs more commonly in males than
females.
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45. Inguinal Hernia
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46. Cont…d
 Inguinal Hernia Can be:-
A) Direct inguinal Hernia
Push their way directly forward
through posterior wall of the
inguinal canal, into a defect in the
abdominal wall.
Less common (20%).
Strangulate Rarely.
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47. Cont…d
B) Indirect inguinal Hernia
Pass through the internal inguinal
ring & then through the external
ring.
Common (80%)
Can Strangulate
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48. Cont…d
 Distinguishing direct from indirect
hernias;
 The best way is to reduce the hernia
& occlude the internal ring with 2
fingers. Ask the pt. to cough - if the
hernia is restrained it is indirect; if
it pops out it is direct.
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49. Cont…d
II) Femoral Hernia
 More Common in women than men.
 Bowel enters the femoral canal,
presenting as a mass in the upper middle
thigh or above the inguinal ligament
where it points down the leg, unlike an
inguinal hernia which points to the groin.
 It is frequently strangulate & irreducible.
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50. Cont…d
III) Para-umbilical Hernias:
 These occur just above or below the umbilicus.
IV) Epigastric Hernias :
 These pass through linea alba above the
umbilicus.
V) Incisional Hernias:
 These follow breakdown of muscle closure
after previous Surgery. If obese, repair is not
easy.
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51. Cont…d
VI) Umbilical Hernia: -
 Results from failure of umbilical orifice
to close.
 Occur most often in obese women &
children & in patients with cirrhosis and
ascites.
 C/F:-
 Only abdominal mass if not
complicated.
 Bowel sound on auscultation.
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52. Cont…d
2. Based on severity
i) Reducible Hernia :- The protruding
mass can be replaced in abdomen.
ii) Irreducible Hernia :- The protruding
mass cannot be moved back into
abdomen.
iii) Incarcerated: - An irreducible hernia
in which the intestinal flow is completely
obstructed.
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53. Cont…d
IV) Strangulated: - an irreducible hernia in
which the blood & intestinal flow is
completely obstructed.
C/F of Strangulation:
 Pain, vomiting
 Swelling of hernial sac,fever
 Lower abdominal sign of peritoneal
irritation
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54. Cont…d
Treatment
1) Mechanical ( reducible hernia only)
 A truss is an appliance having a pad
that is held snugly in the hernial
orifice.
 Does not cure a hernia - it prevents
abdominal contents from entering
hernial sac.
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55. Cont…d
2) Surgical
 Recommended to correct the hernia before
a strangulation occurs which then becomes
on emergency situation.
I. Hernial Sac, is dissected free
II. Contents of sac, are replaced in abdominal
cavity.
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56. Cont…d
III. Neck of sac is legated
IV. Muscle and fascial layers are sawed
together firmely.
V. Strangulated hernia requires resection
of ischemic bowel in addition to
hernia repair.
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57. Disorders of the rectum
1) Haemorrhoids
 Def: - It is an enlarged & congested patch of
mucosa & sub-mucosa at anorectal junction
or
 Are dilated portions of veins in the anal
canal.
 Sites: - at 3, 7, 11 O'clock, on lithotomy
position.
 Hemorrhoid based on its site:-
1) Internal hemorrhoid (if it is above internal
sphincter.) 12/13/2019 57

58. Cont…d
C/F
 Bright red blood occurring at the end of
defecation (Late)
 Mass Per-rectum
 Peri-anal Discomfort
 Pruritus
 Mucosal Discharge
12/13/2019 58

59. Cont…d
 Pain when complicated
 External hemorrhoids are associated
with severe pain due to
inflammation & edema caused by
thrombosis. Clotting of blood
(thrombosis) lead to necrosis &
ischemia.
 Internal Haemorrhoids are painless
until they bleed.
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60. Classification of heamorhoids based on
its stage(severity)
a) 1st degree:- Bleed but no prolapsed
b) 2nd degree :- Prolapsed but reduce
spontaneously
c) 3rd degree :- but need manual
replacement
d) 4th degree :- not returned.
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61. Cont…d
Etiology: - idiopathic
Predisposing factor:-
 Chronic Constipation
 Excessive use of purgative
 Pelvic masses ( Pregnancy )
 Portal HTN
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62. Cont…d
Rx:
 Regulating bowel by laxatives
 Avoid Constipation
 Advice high - residue diet that
contain fruit.
 Sitz bath
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63. Cont…d
 Good personal hygiene & by avoiding
excessive straining during defecation,
haemorrhoid symptoms & discomfort can
be relieved.
 Non-operative Treatment:-
1) Infrared Photocoagulation (rays)
2) Bipolar Diathermy (Heat)
3) Laser Therapy
4) Injecting Sclerosing Solution
12/13/2019 63

64. Cont…d
Conservative Surgical Rx of internal
Haemorrhoid;
A) Rubber - band ligation procedure: - The
haemorthoid is visualized through the
anoscape, & its proximal portion above the
muco-cutaneous lines is grasped with an
instrument. A small rubber band is then
slipped over the hemorrhoid. Tissue distal to
the rubber band becomes necrotic after several
days & sloughs off. It may cause infection,
pain & hemorrhage.
12/13/2019 64

65. Cont…d
B) Cryosurgical Hemorrhoidectomy
 Involves freezing the tissue of the
hemorrhoid for a sufficient time to cause
necrosis.
 Not used widely because the discharge is
very foul-smelling & wound healing is
prolonged.
C) Hemorrhoidectomy, or surgical excision, can
be performed to remove all of the redundant
tissue involved in the process. 12/13/2019 65

66. Ano-rectalAbscess
 Def:
 It is an infection in the para-rectal
spaces.
 Risk Factors:
 Regional enteritis
 Immuno-defcient States (HIV/AIDS)
Many of these abscesses will result in
fistulas.
12/13/2019 66

67. Cont…d
C/M:
 Abscess may occur in a variety of spaces in
& around the rectum.
 Pain
 Foul - Smelling pus
 In Superficial abscess, (Swelling, redness &
tenderness).
 Deeper abscess ( Fever, abdominal Pain )
 Fistula
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68. Cont…d
Mx :
1) Palliative Rx;
 Sitz Bath
 Analgesics
2) Surgical Rx:-
 Incision & drainage
12/13/2019 68

69. Anal fistula
 Def:- It is a tiny, tubular, fibrous tract that
extends into the anal canal from an opening
located beside the anus.
 Cause:
 Fistula usually results from an infection.
 Trauma
 Fissures
 Regional Enteritis
12/13/2019 69

70. Cont…d
C/M
 Pus or stool may leak constantly from the
cutaneous opening
 Passage of flatus or feces from the vaginal or
bladder depending on the fistulas tract.
 Fever
Mgx
 Surgery is always recommended
 Fistulectomy (excision of the fistulous tract)
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71. Anal fissure
 Def:
 It is a longitudinal tear or ulceration in the
lining of the anal canal
 Cause:
 Trauma of passing a large firm stool
 Persistent tightening of the anal canal
secondary to stress or anxiety (leading to
Constipation)
 Child birth
 Trauma 12/13/2019 71

72. Cont…d
C/M
 Extremely Painful Defecation
 Burning
 Bleeding
12/13/2019 72

73. Cont…d
Mgx
 Increase water intake
 Sitz bath
 Emollient Suppositories
 Corticosteroid Suppositories (Relieve
Discomfort)
 Surgery
*Most of the fissures will heal by conservative
measures.
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74. Cancer of the large intestine:
Colon & Rectum
 Tumors of the small intestine are rare;
conversely tumors of the colon &
rectum are relatively common.
Cause: - Unknown
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75. Percentage distribution of colorectal
cancer
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76. Cont…d
Risk factors:-
 Age: - incidence increases with age (most
patients are over age 55). It is the most
common cancer in old age except for
prostates cancer in men.
 Family history of colon cancer
 Chronic inflammatory bowel disease
 Polyp
 A diet high in fat, protein, & beef & low in
fiber
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77. Cont…d
C/M
 It is determined by the location, stage of
cancer & function of the intestinal
segment.
 Unexplained anemia
 Anorexia
 Weight loss
 Fatigue
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78. Cont…d
 Symptoms most Common in right side
lesions;
 Abdominal Pain
 Melena
 Symptoms most commonly associated with
left side lesions.
 Abdominal pain
 Crampy
 Constipation
 Distention
12/13/2019 78

79. Cont…d
 Symptoms associated with rectal lesion;
 Tenesmus
 Rectal Pain
 Feeling of incomplete evacuation after
a bowel movement
 Alternating Constipation & Diarrhea
 Bloody Stool
12/13/2019 79

80. Cont…d
Diagnostic Evaluation
 Fecal occult blood testing
 Barium enema
 Procto-sigmoidoscopy
 Colonoscopy
 Biopsy or cytology smears.
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81. Cont…d
Medical Mgx
 The patient with symptoms of
intestinal obstruction is treated with
IV fluids & nasogastric Suction.
 Treatment depends on the stage of
the disease & related complications.
12/13/2019 81

82. Cont…d
 The most widely used staging method is
duke's classification:-
 Class A- tumor limited to mucosa & Sub-
mucosa
 Class B- Penetration through bowel wall
 Class C- Invasion into regional draining lymph
system.
 Class D- Advanced & widespread regional
metastasis
12/13/2019 82

83. Cont…d
 Radiation Therapy
 Surgical Removal
 It is primary treatment
 Indicated for most class A- lesions & all class- B
and C.
 Segmental Resection with anastomosis
 Temporary Colostomy followed by segmental
resection & anastomosis
 Permanent Colostomy or ileostomy
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84. Cont…d
Complications of Colorectal Cancer
 Partial or Complete bowel obstruction
 Hemorrhage
 Perforation
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85. Nursing Care for Patient with
Colostomy
Colostomy;
 Is the surgical creation of an opening
(stoma) into the colon.
 It can be temporary or permanent
divertion.
 It allows for the drainage or evacuation of
colon contents to the outside of the body.
12/13/2019 85

86. Cont…d
Colostomy Irrigation;
 It is washing out of the intestinal content
through the stoma.
Indication
a) It is done to permit escape of feces when
there is an obstruction of the large bowel
or a known lesion, such as cancer, that
will eventually cause an obstruction.
12/13/2019 86

87. Cont…d
b) It also may be done to permit healing of the
bowel distal to it after an infection,
perforation or traumatic injury since it
diverts the fecal stream from the affected
area.
c) It may be done as a palliative measure in the
treatment of an obstruction caused by an
inoperable growth of the colon or if the
rectum must be removed to treat cancer.
d) It may be done to provide a permanent
means of bowel evacuation.
12/13/2019 87

88. Cont…d
Purpose of colostomy irrigation
1. To encourage a bowel motion in a recently
established colostomy and to ensure that the
opening is patent.
2. To relieve constipation in patients who has
difficulty managing their colostomy.
3. To teach the patient how to establish
regularity of evacuation through the
colostomy.
4. To reduce distention before closure of
colostomy 12/13/2019 88

89. Cont…d
 Read about/Remind your fundamentals of
nursing course about;
 The equipments needed.
 The procedure.
 The special considerations.
 Develop nursing care plan for a patient with
colostomy.
12/13/2019 89