GI System Rectal Disorders gjuPart 3.pdf

Dr. Mohammad Alsadi, RN, Ph.D.
Dr. Mohammad Alsadi, RN Ph.D.
Dr. Hedaya Hina, RN, Ph.D.
Nursing care for adults with duodenal and
rectal conditions:
Anal abscess , Anal fistula, Anal fissure,
Pilonidal sinus, and Haemorrhoids

Intended Learning Outcomes
• On completion of this chapter, the learner will be able to:
• Identify the definition and/or types of Anal abscess , Anal fistula Anal
fissure, Pilonidal sinus, and Haemorrhoids
• Understand the Pathophysiology of these diseases.
• Know the possible causes of these diseases.
• Understand the etiology, clinical manifestations, and management of
these diseases.
• Describe the pharmacotherapies of of these diseases.
• Use the nursing process as a framework for care of patients with
these diseases.
• Describe the dietary, pharmacologic, and surgical treatment of these
diseases

Copyright © 2022 Wolters Kluwer · All Rights Reserved
Anorectal Conditions
❖Proctitis
❖Anorectal abscess
❖Anal fistula
❖Anal fissure
❖Hemorrhoids
❖Pilonidal sinus or cyst

❖Are dilated portions of veins in the anal canal.
❖Types are:
1. Internal: above internal sphincter
2. External: outside external sphincter
❖Etiology and pathophysiology
o Increased anal pressure and weakened
connective tissue results in downward
displacement, which results in dilation
o Risk factors: pregnancy, constipation, straining,
diarrhea, heavy lifting, prolonged standing and
sitting, obesity, and ascites
Hemorrhoids (1 of 3)
Copyright © 2020 by Elsevier, Inc. All rights reserved. 4

Internal hemorrhoids are classified by their degree of prolapse:
•First degree—do not prolapse and protrude into anal canal
•Second degree—prolapse outside the anal canal during
defecation but reduce spontaneously
•Third degree—prolapsed to the extent that they require manual
reduction
•Fourth degree—prolapsed to the extent that they may not be
reduced and are at risk for strangulation and thrombosis

Fig. 42-16

❖Internal: bleeding with defecation; pain, prolapse
(pressure, protruding mass)
❖External: reddish blue color; itching, burning,
edema
o Thrombosis (i.e., clotting of blood within the hemorrhoid)
lead to: bluish-purple, palpable; pain and inflammation;
bleeding with defecation
Manifestations

❖Diagnosis:
o External: Inspection and digital examination
o Internal: digital examination, anoscopy, sigmoidoscopy
❖Therapy:
o High-fiber diet, increased fluids—prevent constipation and
reduce straining
o Ointments, creams, suppositories, anesthetics, stool
softeners
Diagnostic Studies and Interprofessional
Care

❖Treatment
o External: conservative unless thrombosed
o Internal: rubber band ligation, infrared
coagulation, sclerotherapy
o Hemorrhoidectomy—surgical excision
Interprofessional Care

❖Conservative: Education
o Prevent constipation
o OTC drugs
o When to seek health care: bleeding, prolapse
o Sitz bath
❖Postoperative
o Pain control: opioid, NSAIDs, topical
o Wound healing; packing, dressing change
o Promote defecation
o Education: complications, avoid constipation
Nursing Management

❖ a longitudinal tear or ulceration in the lining of the anal canal
❖ Causes: trauma from hard stool, anal trauma, local infection
(STDs), inflammation, childbirth, and anal intercourse
❖ High pressure and poor blood supply results in ischemia which
results in ulceration
❖ Symptoms: severe anal pain especially with defecation and
direct pressure; blood
❖ Diagnosis: direct examination
Anal Fissures

❖ Treatment:
❖ fiber, fluids, sitz bath, topical analgesia, stool softeners;
❖ Therapies such as perianal or intra-anal application of
nitroglycerin ointment, calcium channel blockers, minoxidil, or
botulinum toxin injections have increased the rate of healing
and lowered pain levels in chronic anal fissures; these
therapies should be tried before surgery. These agents work by
increasing blood supply to the region and relaxing the anal
sphincter.
❖ If fissures do not respond to conservative treatment, surgery is
indicated. . The procedure of choice is the lateral internal
sphincterotomy with excision of the fissure.
Anal Fissures

❖Sphincterotomy : The operation usually takes about 15
minutes. Your surgeon will make a small cut on the skin near your
back passage. They will cut the lower part of the internal
sphincter muscle. This will relieve the spasm in the sphincter,
allowing a better blood supply to heal the fissure.

❖ An anorectal abscess is a collection of pus in the area of the
anus and rectum.
❖ Causes: People with Crohn’s disease or immunosuppressive
conditions such as AIDS are particularly susceptible to these
infections. Many of these abscesses result in fistulas.
❖ An abscess may occur in a variety of spaces in and around the
rectum.
❖ Manifestations: perianal discomfort and itching, pain with
defecation, foul-smelling drainage (pus, mucous, or blood),
fever; sepsis
❖ Diagnosis: rectal examination
Anorectal Abscess

❖Treatment: Prompt surgical treatment to incise and
drain the abscess is the treatment of choice, to
prevent complications such as fistula formation,
fecal incontinence, and sepsis.
❖Nursing care: moist heat, positioning, low-fiber diet;
Education: wound care, perianal hygiene, follow-up
care
Anorectal Abscess

Common Sites for Anorectal Abscesses
and Fistula Formation
(Fig. 42-18)

❖Abnormal tract between two hollow organs or a
hollow organ and the skin
❖Complication—increased morbidity and mortality,
extended length of stay, and increased costs
❖Simple—1 short direct tract
❖Complex—multiple organs, abscess, opens into base
of wound
❖Output: low less than 200 mL/day; moderate 200 to
500 mL/day; high greater than 500 mL/day
❖Early signs: fever and abdominal pain
Fistulas

❖Abnormal tunnel from anus or rectum to skin,
vagina, or buttocks
o Precedes or due to abscess or complication from Crohn’s
disease
o Drainage: bloody, purulent, or fecal.
Purulent drainage or stool may leak constantly from the
cutaneous opening
❖Treatment:
o Surgery as few fistulas heal spontaneously: fistulotomy
(i.e., excision of the fistulous tract). Fistulas recur in up to
half of patients
Anal Fistula

A fistulotomy is the surgical opening of a fistulous tract. They
can be performed by excision of the tract and surrounding
tissue,

❖Fistula management:
o Identify tract
o Maintain fluid and electrolytes: IV replacement
o Control infection
o Protect surrounding skin: WOCN consult
o Manage output: Monitor I & O; drainage
o Nutritional support: dietician; high-calorie, high-
protein enteral or parenteral nutrition
❖Most heal spontaneously; some require surgery
Nursing and Interprofessional
Management

❖ Small tract under the skin between buttocks in lower sacrum
area
❖ Causes: Current theories suggest that it results from local
trauma, causing penetration of hairs into the epithelium and
subcutaneous tissue. It may also be formed congenitally by an
infolding of epithelial tissue beneath the skin.
❖ Hair frequently is seen protruding from these openings, and
this gives the cyst its name, pilonidal (i.e., a nest of hair)
❖ The cysts rarely cause symptoms until adolescence or early
adult life, when infection produces an irritating drainage or an
abscess. Perspiration and friction easily irritate this area
Pilonidal Sinus or Cyst

❖ Treatment of abscess—irrigation and drainage
❖ Nursing: warm, moist, heat; positioning
o Education: avoid dressing contamination and straining
o The abscess is incised and drained under local anesthesia.
After the acute process resolves, further surgery might be
indicated to excise the cyst and any secondary sinus
tracts.
Pilonidal Sinus or cyst

Assessment of the Patient with an
Anorectal Condition
❖Health history
❖Pruritus, pain, or burning
❖Elimination patterns
❖Diet
❖Exercise and activity
❖Occupation
❖Inspection of the area

Planning and Goals for the Patient with an
Anorectal Condition
❖Major goals may include:
o Adequate elimination patterns
o Reduction of anxiety
o Pain relief
o Promotion of urinary elimination
o Management of the therapeutic regimen
o Absence of complications

Nursing Interventions for the Patient with
an Anorectal Condition
❖Encourage intake of at least 2 L of water a day
❖Recommend high-fiber foods
❖Bulk laxatives, stool softeners, and topical
medications
❖Promote urinary elimination
❖Hygiene and sitz baths
❖Monitor for complications
❖Educate on self-care

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Bowel Resection and
Ostomy Surgery

❖Indications
o Remove cancer
o Repair perforation, fistula, or traumatic injury
o Relieve obstruction or stricture
o Treat an abscess, inflammatory disease or
hemorrhage
Surgical Resection

❖ A surgically created opening on the abdomen that allows the
discharge of body waste when the normal elimination route is
no longer possible. The outermost part that is visible is a
stoma. The stoma is the result of the large or small bowel
being brought to the outside of the abdomen and sutured in
place.
❖ Named for location:
1. An ostomy in the Ileum—ileostomy (involuntary drainage)
2. An ostomy in the Colon—colostomy (possible regulation)
❖ Named for Anatomic site: ascending, transverse, sigmoid
- May be temporary or permanent.
Ostomy

Colostomy Irrigation: A method of cleaning the distal colon
and rectum of faeces and mucus, by instilling water into the
colon via the stoma at regular intervals.
Bowel Regulation: A method of routinely performing colostomy
irrigation to empty the colon at a scheduled time once every day
or every second day, in order to establish a regular bowel
pattern.

o The more distal the ostomy, the more functioning bowel
remains and the more likely that the intestinal contents will
resemble the feces that would have been eliminated from an
intact colon and rectum.
o Ileostomy output will be a liquid to thin paste since it did not
enter the colon. Patients have no control over ileostomy
drainage; it is involuntary. An ileostomy drains frequently,
and the patient must wear an ostomy appliance (pouch) to
collect the drainage.
o Sigmoid colostomy output resembles normal formed stool.
Some patients can regulate emptying time with colostomy
irrigation and may not need to wear a pouch.
Ostomy

Types of Ostomies
(Fig. 42-10)

Urostomy: related to the renal system
A urostomy is a surgical procedure that creates a
stoma (artificial opening) for the urinary system.

o Ostomies may be temporary or permanent. For
example, the person with a draining fistula may
need a temporary ostomy to prevent stool from
reaching the diseased area.
Cancer involving the rectum requires a permanent
ostomy if all bowel distal to the ostomy is removed.
Ostomy

❖ Psychological preparation and emotional support
❖ Education
❖ Wound, Ostomy, and continuance nurse (WOCN)
consult and education to determine the patient’
s’
ability to perform self-care, identify support
systems, and determine any modifications that
could promote learning during recovery.
❖ Stoma site selection
o Within rectus muscle (decreased risk of
hernia)
o Flat surface (create seal less likely to leak)
o Patient able to see but discreetly hidden
under clothing
Preoperative Care

The “ostomy triangle” is bounded by the
anterior superior iliac spine, the pubic
tubercle, and the umbilicus. One must
attempt to place the stoma within the
rectus muscle within this triangle as it has
been shown to lend support to the stoma
and decrease the risk of stoma prolapse.

❖ Postoperative care
o Wound management
▪ Closed wound—monitor incision/sutures
▪ Open wound—dressing changes; monitor drainage
amount, color, and consistency. The drainage is usually
serosanguineous
▪ Assess wound/drainage for inflammation/infection
▪ Monitor fever and WBCs
▪ Assess for complications: delayed wound healing,
hemorrhage, fistulas, and infection
o Ostomy characteristics
Normal: pink—red; mild swelling; small amount blood
Postoperative Care (1 of 3)

❖ Postoperative care
▪ A dusky blue stoma indicates ischemia; a brown-black
stoma indicates necrosis. Assess and document stoma
color every 4 hours and ensure that there is no excess
bleeding. Report any sustained color changes or
bleeding to the HCP. Edema will resolve over the first 6
weeks

❖ Colostomy function
o Record volume, color, consistency of drainage
o Excess gas common for 2 weeks—temporary
❖ Ileostomy function
o 24 to 48 hours—the amount of drainage from an
ileostomy may be negligible
o Peristalsis returns— ileostomy output expected 1500 to
1800 mL/day
o Monitor fluid and electrolyte (Na+, K+) balance
o Bowels adapts and increases absorption—feces thickens
and volume decreases to ~500mL/day

❖ Patient and caregiver education
o Basic ostomy management skills
o Diet: balanced with adequate fluids; avoid odor, gas, and
diarrhea-producing foods
o Resources for problems (home care, WOCN)
❖ Emotional support—body image changes
o Sexual activity, social life, work
o Resume ADLs 4 to 6 weeks
Colostomy Care (1 of 2)

❖Pouching system
o Adhesive skin barrier and pouch
o Empty when 1/3 full to prevent pulling and leaks
o Transparent pouch—visualize stoma
o Pouch change—assess skin
o Failed pouch—change immediately
o Drainable or closed end pouch according to site
o Charcoal filters—deodorize and release flatus
o Irrigation for regulation (distal colon ostomy)
o Bath, shower, swimming—no harm to stoma
Colostomy Care (2 of 2)

❖ A colostomy in the ascending
and transverse colon has
semiliquid stools. Have the patient
use a drainable pouch. A
drainable pouch may last up to 4 to
7 days.
❖ A colostomy in the sigmoid or
descending colon has semiformed
or formed stools. The patient can
use a drainable pouch or choose a
disposable, closed end pouch
changed every day.

o Secure pouching—stool caustic to skin
o Best pouch—open-ended, drainable
o Fluid intake—at least 2 to 3 L/day
▪ Teach about fluid and electrolyte imbalance; esp. Na+
o Increased risk of obstruction—narrowed lumen
▪ Chew thoroughly; especially nuts, raisins, popcorn,
coconut, mushrooms, olives, foods with skins, dried
fruits, and meats with casings
Ileostomy Care

❖Individualized responses—provide accurate,
information, emotional support, and education
o Positive—curative
o Grief, anger, depression, anxiety, and fear
o Emotions may alter participation in care
o Discuss body image and self-esteem; identify
coping strategies and support systems
o Support sites: www.wocn.org or
www.ostomy.org
o Support groups; hospital visitor programs
Adaptation to an Ostomy

❖Sexual function
o Teach patient the effects from surgery
▪ Nerve or vascular disruption to genitalia
▪ Radiation, chemotherapy, fatigue, overall health
o Males—concern with erection and ejaculation
▪ May be temporary for 3 to 12 months
o Females—vaginal dryness and  sensation
▪ Arousal and orgasm concerns; Pregnancy is possible
o Body-image—fear rejection
o Teach about alternatives for pouching/security
Sexual Function

GI System Rectal Disorders gjuPart 3.pdf

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