Medical surgical nursing

1. Abnormalities of Fecal Elimination

2. Constipation
• Constipation is a problem that affects all ages. However, it is
a common problem in older adults and is often a concern to
elders and clinicians.
• In older people, acute bouts of constipation can occur with
acute illness or dietary alterations.
• In contrast, chronic constipation usually has an insidious
onset of many years, often dating to childhood.

3. Introduction cont’d..
•No widely accepted clinically useful definition of
constipation exists.
•Healthcare providers usually use the frequency of bowel
movements (i.e., less than three bowel movements per week)
to define constipation.

4. Definition
• Definition of constipation is simply a change in bowel habit or
defecatory behavior that results in acute or chronic symptoms
or diseases that would be resolved with relief of the
constipation.
• Constipation can be defined as a clinical condition
characterized by infrequent bowel opening and/or passage of
hard stools.

5. Cont’d..
• People more likely to become constipated are women,
particularly pregnant women, patients who recently had
surgery, older adults, and those of lower socioeconomic
status (NIDDK, 2014c).
• Notably, constipation is a symptom and not a disease;
however, constipation can indicate an underlying disease or
motility disorder of the GI tract.

6. Aetiology /Caused of Constipation
• Drugs (Anticholinergic agents, Antidepressants,
Anticonvulsants, Antispasmodics (muscle relaxants), Calcium
channel antagonists, Diuretic agents, Opioids, Aluminum- and
calcium-based antacids, and Iron preparations).
• Disease of the anus, rectum and colon e.g. fissure,
haemorrhoids, and cancer
• Functional: irritable bowel syndrome
• Metabolic disease: e.g. hypothyroidism, hypercalcaemia

7. Aetiology /Caused of Constipation
cont’d..
• Many people develop constipation because they do not take
the time to defecate or ignore the urge to defecate.
• Constipation is also a result of dietary habits (i.e., low
consumption of fiber and inadequate fluid intake), Fiber is
particularly important to bowel health because it increases
the bulk of stool, generally easing the passage. More
importantly, it also promotes optimal fermentation, providing
good bowel wall health (McRorie, 2015).
• Lack of regular exercise, and a stress-filled life (NIDDK,
2014c).

8. Pathophysiology of constipation
• Two mechanisms explain the Pathophysiology of constipation.
Colonic motility dysfunction, or dysmotility, is failure of
coordinated motor activity to move stool through the colon.
• It is sometimes associated with: dietary factors, medications
that can alter motility; or systemic disease (e.g. neurologic,
metabolic, or endocrine disorders).
• Others exhibit abnormalities of the enteric nerves, such as
decreased volume of interstitial cells of Canal (ICC) and other
neural elements.

9. Pathophysiology of constipation
cont’d..
• The second mechanism involves pelvic floor dysfunction, or
disorders of the anorectum and pelvic floor, which result in
outlet dysfunction and an inability to adequately, evacuate
rectal contents.
• Functional constipation may occur as a result of disordered
movement through the sigmoid colon and/or anorectum.
• Both mechanisms coexist in some patients, making it
difficult to determine the exact underlying mechanisms for
constipation.

10. Signs and Symptom
•Stools are often hard
•Abnormal bloating
•Excessive flatulence
•Hard fecal matter with or without blood

11. Assessment and Diagnostic Findings
• History taking
• Physical examination
• Barium enema or sigmoidoscopy, and stool testing for occult
blood. These tests are used to determine whether this
symptom results from spasm or narrowing of the bowel.
• Anorectal manometry (i.e., pressure studies such as a balloon
expulsion test) may be performed to assess malfunction of
the sphincter.

12. Assessment and Diagnostic Findings
cont’d…
• Defecography and colonic transit studies can also assist in the
diagnosis because they permit assessment of active anorectal
function.
• Tests such as pelvic floor magnetic resonance imaging (MRI)
may identify occult pelvic floor defects (Basson, 2015a).
• Other like serum hormonal level e.g. thyroxine,
triiodotyronine, thyroid stimulating hormone to exclude
hypothyroidism

13. Complications
• Megacolon
• Anal fissure/tears
• Haemorrhoids
• Rectal bleeding

14. Treatment objective
• Identify and eliminate causes
• Evacuate hard faccal matter

15. Medical management
• Stimulant laxative
• Bisacodyl tablet 10mg orally at night
• Suppositories 10mg per rectum at night
• Liquid paraffin 5-15ml
• Caution: Laxatives should generally be avoided. Most times
these drugs are needed for only a few days

16. Nursing management
•Educate the patient/client to avoid precipitants
•Encourage to take high fibre diet (include fruit and
vegetable)
•Adequate fluid intake

17. Diarrhea

18. Introduction
• Diarrhea is one of the most common complaints faced by
internists and primary care physicians and accounts for many
referrals to gastroenterologists.
• The Centers for Disease Control and Prevention (CDC)
estimates that 76 million food borne illnesses occur annually
in the United States, resulting in 325,000 hospitalizations and
5200 deaths.
• Most of the case fatalities and morbidities occur in children
below the age of 5 years.

19. Definition
• Diarrhea is generally defined as the passage of abnormally
liquid or unformed stools associated with increased frequency
of defecation.
• Increased frequency is defined by three or more bowel
movements a day.
• However, most patients base their diarrhea on the consistency
of the stool rather than the frequency of bowel movements.
• Since the consistency of the stool is difficult to quantified,
diarrhea is often defined based on stool frequency or the stool
weight alone.

20. Diarrhea can be classified
• Acute diarrhea is sudden onset in a previously healthy person,
self-limiting, lasting 1 or 2 days; persistent diarrhea typically
lasts between 2 and 4 weeks; resolves without sequelae.
• Acute and persistent diarrheas are frequently caused by viral
infections (e.g., Norwalk virus).
• In addition, some drugs can cause acute or persistent diarrhea,
including some antibiotics (e.g., erythromycin) and magnesium-
containing antacids (e.g., magnesium hydroxide (Milk of
Magnesia).

21. Chronic Diarrhea
• Chronic diarrhea persists for more than 4 weeks, associated
with recurring passage of diarrhea stools, fever, loss of
appetite, nausea, vomiting, weight loss and chronic weakness.
• Chronic diarrhea may be caused by adverse effects of
chemotherapy, antiarrhythmic agents, antihypertensive agents,
metabolic and endocrine disorders (e.g., diabetes, Addison
disease, thyrotoxicosis), malabsorptive disorders (e.g., lactose
intolerance, celiac disease), anal sphincter defect, Zollinger–
Ellison syndrome, acquired immune deficiency syndrome
(AIDS), and by parasitic or Clostridium difficile infections
(NIDDK, 2014d).

22. Common causes of Diarrhea
• Bacteria e.g. Vibrio cholera, Shigella, Escherichia Coli,
Campylobacteria jejuni, Yersinia enterocolitica,
Staphylococcus, Vibrio Parahemolyticus, and Clostridium
difficile
• Virus e.g. Rotavirus, Adenoviruses, Calciviruses, and
Astroviruses
• Norwalk agents and Norwalk-like viruses

23. Common causes of Diarrhea
• Parasite e.g. Entameba Histolytica, Giardia Lamblia,
Cryptosporidium, and Isospora
•Metabolic disease e.g. Hyperthyroidism, Diabetes
mellitus, and Pancreatic insufficiency
• Food Allergy e.g. Lactose intolerance, Irritable bowel
syndrome

24. Drugs causing Diarrhea
• Laxatives
• Antacid containing magnesium
• Antineoplastic drugs
• Antibiotics e.g. Clindamycin, Tetrecyclines, sulfonamides, any
broad-spectrum antibiotic
• Antihypertensive e.g. methyldopa, Angiotensin-coverting
enzyme inhibitor, Angiotensin receptor blockers, α-adrenergic
receptor blockers

25. Drugs causing Diarrhea cont’d..
• Cholinergic drugs, e.g. Neostigmine
• Cardiac agents e.g. Quinidine, Digoxin
• Nonsteroidal anti-inflammatory drugs
• Misoprostol
• Colchicines
• Proton pump inhibitors
• H2- receptor blockers

26. Transmission
• Most of the diarrhea agents are transmitted by the fecal-oral
route
• Cholera: water-borne disease; transmitted through water
contaminated with feces
• Some viruses (such as rotavirus) can be transmitted through
air
• Nosocommial transmission is possible
• Shigelloses(blood dysentery) is mainly transmitted person- to
person

27. Pathophysiology
• There are numerous causes of diarrhea in almost all cases, it
manifestation can be described by four basic mechanisms.
More than one of the four mechanisms can be involved in the
Pathophysiology of a given case. These mechanisms are;
• Osmotic diarrhea
• Secretory diarrhea
• Inflammatory and infection diarrhea
• Diarrhea associated with deranged motility

28. Osmotic Diarrhea
• Absorption of water in the intestines is dependent on
adequate absorption of solution.
• If excessive amounts of solutes are retained in the intestinal
lumen, water will not be absorbed and diarrhea will result.
Osmotic diarrhea typically results from one of two situation:
• ingestion of a poorly absorbed substrate; the offending
molecule is usually a carbohydrate or divalent ion. Common
example include mannitol or sorbitol, Epson salt(MgSO4) and
some antacids(MgOH2).

29. Osmotic Diarrhea cont’d..
• Malabsorption: inability to absorb certain carbohydrate is the
most common defect in this category of diarrhea, but it can
result virtually any type of Malabsorption.
• A common example of Malabsorption, afflicting many adults
human and pet is lactose intolerance resulting from a
deficiency in the brush border enzymes lactase.
• In such cases a moderate quantity of lactose is consumed
(usually as milk), but cannot be effectively hydrolyzed into
glucose and galactose for absorption.

30. Osmotic Diarrhea cont’d..
• The osmotically-active lactose is retained in the intestine
lumen, where it “holds” water.
• To add insult of injury, the unabsorbed lactose passes into
the large intestine where it is fermented by colonic
bacteria, resulting in production of excessive gas.
• A distinguishing feature of osmotic diarrhea is that it stops
after the patient is fasted or stops consuming the poorly
absorbed solute.

31. Secretory Diarrhea
• Large volumes of water are normally secreted into the small
intestine lumen, but a large majority of this water is
efficiently absorbed before reaching the large intestine.
Diarrhea occurs when secretion of water into the intestinal
lumen exceed absorption.
• Many millions of people have died of the secretory diarrhea
associated with cholera. The responsible organism, vibro
cholera, produces toxins, which strongly activates adenyly
cyclase, causing a prolonged increase in intracellular
concentration of cyclic AMP within crypt enterocytes.

32. Secretory Diarrhea cont’d..
• This change results in prolonged opening of the chloride
channels that are instrumental in secretion of water from
the crypts allowing uncontrolled secretion of water.
Additionally, cholera toxin affects the enteric nervous
system, resulting in an independent stimulus of secretions.
• Exposure to toxins from several other types of bacterial (eg
E. coli heat-labile toxin) induces the same series of steps
and massive secretory diarrhea that is often lethal unless
the person is aggressively treated to maintain hydration

33. Secretory Diarrhea cont’d..
• In addition to bacteria toxin, a large number of other agents
can induce secretory diarrhea by turning on the intestinal
secretory machinery including; some laxative, hormones
secreted by certain types of tumours(e.g. Vasoactive
intestinal peptide), a broad range of drugs( e.g. some types
of asthma medications, antidepressant, cardiac drugs),
certain metals, organic toxins and plant product(e.g.
arsenic, insecticides, mushroom toxins, caffeine) and in
most cases, secretory diarrheas will not resolve during a 2-3
day fast.

34. Inflammatory and infectious Diarrhea
• The epithelium of the digestive tube is protected from insult
by a number of mechanisms constituting the gastrointestinal
barrier, but like many barriers, it can be breached.
• Disruption of epithelium results not only in exudation of serum
and blood into the lumen but often is associated with
widespread destruction of absorptive epithelium.
• In such cares, absorption of water occurs very inefficiently
and diarrhea results. Examples of pathogens frequently
associated with infection diarrhea include:

35. Inflammatory and infectious Diarrhea
• Bacteria: salmonella, E. coli, Campylobacter
• Viruses: rotaviruses, coronaviruses, paroviruses(canine and
feline), norovirus
• Protozoa: coccidian species, Cryptosporium, Giardia, the
immune response to inflammatory conditions in the bowel
contributes substantively to development of diarrhea.
• Activation of white blood cells lead them to secrete
inflammatory mediators and cytokines which can stimulate
secretion, in effect imposing a secretory component on top of
an inflammatory diarrhea.

36. Inflammatory and infectious Diarrhea
• Reactive oxygen species from leukocytes can damage or kill
(Malabsorption) diarrhea are added to the problem.

37. Diarrhea associated with Deranged motility
• In order for nutrient and water to be efficiently absorbed,
the intestinal contents must be adequately exposed to the
mucosal epithelium and retained long enough to allow
absorption.
• Disorders in motility than accelerate transit, time could
decrease absorption, resulting in diarrhea even if the
absorption process per se was proceeding properly.
• Alterations in intestinal motility (usually increased
propulsion) are observed in many types of diarrhea.
• What is not usually clear, and very difficult to demonstrate,

38. Clinical Manifestations
• Increased frequency and fluid content of stools,
• Abdominal cramps,
• Distention,
• borborygmus (i.e., a rumbling noise caused by the movement
of gas through the intestines),
• Anorexia and thirst.
• Painful spasmodic contractions of the anus
• Tenesmus (i.e., ineffective, sometimes painful straining with
a strong urge) may occur with defecation.

39. Clinical Manifestations cont’d..
• Dehydration and to fluid and electrolyte imbalances.
• Voluminous, greasy stools suggest intestinal malabsorption
(impaired transport across the mucosa).
• Presence of blood, mucus, and pus in the stools suggests
inflammatory enteritis or colitis.
• Oil droplets on the toilet water may be suggestive of
pancreatic insufficiency.
• Nocturnal diarrhea may be a manifestation of diabetic
neuropathy (NIDDK, 2014d; Weber & Kelley, 2014).

40. Complications
• Hypovolaemic shock with multiple organ failure
• Septicaemia intestinal
• Perforation
• Gastrointestinal bleeding
• Paralytic ileus

41. Assessment and Diagnostic Findings
• History Diarrhea
• Duration, onset, frequency, consistency colour, volume blood or
mucous?
• Associated symptoms: abdominal pain, nausea, fever,
headache, fatigue?
• What and where has he eaten recently?
• Travel history?
• Are any other family members complaining of the same
symptoms?

42. History Diarrhea
•Aggravating or relieving factors?
•Ask the mother if the child has vomiting present?
•Ask about micturition?
•Signs and symptoms of dehydration? Eg. Thirst

43. Physical Examination
•Vitals signs
•Anthropometric measures
•Signs of dehydration
•Abdominal examination
•Systemic examination
The following diagnostic tests may be performed:
•Full blood cell count (FBC);
•Serum chemistries;

44. Physical Examination cont’d..
• Urinalysis;
• Routine stool examination; and
• Stool examinations for infectious or parasitic organisms,
• Bacterial toxins, blood, fat, electrolytes, and
• White blood cells.
• Endoscopy or barium enema may assist in identifying the
cause (NIDDK, 2014d).

45. Treatment objective
•Achieve adequate hydration
• Eliminate infection agent(where possible)
•Treat complication

46. Medical management
Rehydration with:
• Oral Rehydration Therapy-ORT (low osmolality)
• For mild to moderate dehydration
• 500ml orally over 2-3 hours, 3-4 time daily
• Intravenous sodium chloride 0.9%
• 1 litre 2-6 hourly for moderate- to-severe dehydration
• Alternate with Darrow’s solution depending on serum
potassium

47. Rehydration
• Children
• Used of zink supplement shortens the diarrhea in children
• 20mg per day for 10-14 days
• Under 6 months old, 10mg per day
• Specific anti-infective agents for infection diarrhea e.g.
metronidazole

48. Anti-diarrheal
• Anti-diarrheal are classified on the basis of their
chemical class or pharmacologic mechanism of action
into:
Antiperistalsis drugs
• These drugs act by stimulating µ opioids receptors in
musculature of small and large intestine to normalize
peristaltic intestinal movement example Dihpenoxylate
and atropine(lomotil), Loparamide
Adsorbents

49. Anti-diarrheal cont’d..
• Miscellaneous Agents
• Bismuth subsalicylate
• Adsorbent, decrease the secretion of water into the bowl
• Lactobacillus
• Products containing non-toxic strains of lactobacillus
acidophilus are intended to replace normal bacterial flora that
is lost during the administration of oral antibiotics
• Lactase enzymes

50. Anti-diarrheal cont’d..
• Anti-infection agents
• Eradicate the organism and decrease the duration of symptoms
• Nitrofuroxazide
• Metronidazole
• Anticholinergic drugs
• Decrease bowel motility, so increase fluid absorption
• Decrease abdominal cramping

51. Nursing Management
• Assessment of Dehydration
Mild Moderate Severe
Appearance Irritable thirsty Irritable very thirsty Lethargy coma, or unconscious
Anterior frontanelle Normal Depressed Marked depressed
Eyes Normal Sunken Sunken
Tongue Normal Dry Very dry furred
Skin Normal Slow retraction Very slow retraction
Breathing
Normal Rapid Very rapid
Pulse Normal Rapid and low volume Feeble or imperceptible
Urine Normal Dark Scanty

52. Nursing Management cont’d..
• During an episode of diarrhea, the patient is encouraged to
increase intake of liquids and foods low in bulk until the
symptoms subside.
• When the patient is able to tolerate food intake, the patient
should avoid caffeine, alcoholic beverages, dairy products,
and fatty foods for several days.
• Antidiarrheal medications such as diphenoxylate with
atropine or loperamide may be taken as prescribed.

53. Nursing Management cont’d..
• Intravenous (IV) fluid therapy may be necessary for rapid
rehydration in some patients, especially in older adults and in
patients with pre-existing GI conditions.
• It is important to monitor serum electrolyte levels closely.
• Reports evidence of dysrhythmias or a change in a patient’s
level of consciousness.
• The patient should follow a perianal skin care routine to
decrease irritation and excoriation.

54. Thank you