Week 11

• Constipation


  Fewer than three bowel movements weekly or bowel movements that are hard, dry, small, or difficult to pass
• People more likely to become constipated


  • Women, particularly pregnant women
  • Patients who recently had surgery
  • Older adults
  • Non-Caucasians
  • Those of lower socioeconomic status
• Constipation is a symptom and not a disease
• Constipation can be caused by certain medications
• Three classes of constipation

  • Functional constipation
  • Slow-transit constipation
  • Defecatory disorders
• Functional constipation


  Involves normal transit mechanisms of mucosal transport, most common and can be successfully treated by increasing intake of fiber and fluids
• Slow-transit constipation


  Caused by inherent disorders of the motor function of the colon (e.g., Hirschsprung disease), characterized by infrequent bowel movements
• Defecatory disorders


  Caused by dysfunctional motor coordination between the pelvic floor and anal sphincter, can cause not only constipation but also fecal incontinence
• Clinical manifestations of constipation

  • Fewer than three bowel movements per week
  • Abdominal distention
  • Pain and bloating
  • Sensation of incomplete evacuation
  • Straining at stool
  • Elimination of small volume lumpy, hard, dry stools
• Complications of constipation


  • Increased arterial pressure
  • Fecal impaction
  • Fecal incontinence
  • Hemorrhoids
  • Fissures
  • Rectal prolapse
  • Megacolon
• Medical management of constipation

  • Health education
  • Exercise
  • Bowel habit training
  • Increased fiber and fluid intake
  • Judicious use of laxatives
  • Patients can be educated to sit on the toilet with legs supported and to utilize the gastrocolic reflex
  • Biofeedback
  • Enemas and rectal suppositories
• Diarrhea


  Increased frequency of bowel movements (more than 3 per day) with altered consistency (i.e., increased liquidity) of stool

  
• Symptoms associated with diarrhea

  • Urgency
  • Perianal discomfort
  • Incontinence
  • Nausea
• Causes of diarrhea


  • Increased intestinal secretions
  • Decreased mucosal absorption
  • Altered motility
• Classification of diarrhea


  • Acute diarrhea (self-limiting, lasting 1 or 2 days)
  • Persistent diarrhea (typically lasts between 2 and 4 weeks)
  • Chronic diarrhea (persists for more than 4 weeks and may return sporadically)
• Assessment of diarrhea


  • Abdominal auscultation
  • Palpation for tenderness
  • Inspection of the abdomen, mucous membranes, and skin
• Complications of diarrhea


  • Dehydration
  • Cardiac dysrhythmias
  • Metabolic acidosis
  • Muscle weakness
  • Paresthesia
  • Hypotension
  • Anorexia
  • Hypokalemia
  • Drowsiness
  • Irritant dermatitis
• Medical management of diarrhea

  • Controlling symptoms
  • Preventing complications
  • Eliminating or treating the underlying disease
  • Infection control measures
  • Medications (antibiotics, anti-inflammatory agents, antidiarrheal agents, diphenoxylate with atropine)
• Fecal incontinence


  Recurrent involuntary passage of stool from the rectum for at least 3 months
• Factors that influence fecal incontinence

  • Ability of the rectum to sense and accommodate stool
  • Amount and consistency of stool
  • Integrity of the anal sphincters and musculature
  • Rectal motility
• Medical management of fecal incontinence

  • Lifestyle modification (stress reduction, adequate sleep, exercise regimen)
  • Soluble fiber (diet)
  • Antibiotics
  • Antidiarrheal agents (for diarrhea and fecal urgency)
  • Antispasmodic agents (for pain)
  • Antidepressants (for anxiety)
• Celiac disease


  A disorder of malabsorption caused by an autoimmune response to consumption of products that contain the protein gluten
• Foods containing gluten


  • Wheat
  • Barley
  • Rye
  • Other grains
  • Malt
  • Dextrin
  • Brewer's yeast
• Groups more likely to develop celiac disease

  • Women (afflicted twice as often as men)
  • Any age (genetically predisposed)
  • More common among Caucasians
  • Those with type I diabetes, Down syndrome, and Turner syndrome
• Common GI clinical manifestations of celiac disease

  • Fatigue
  • Diarrhea
  • General malaise
  • Steatorrhea
  • Abdominal pain
  • Abdominal distention
  • Flatulence
  • Weight loss
• Non-GI signs and symptoms of celiac disease

  • Depression
  • Hypothyroidism
  • Migraine headaches
  • Osteopenia
  • Anemia
  • Seizures
  • Paresthesias in the hands and feet
  • Red, shiny tongue
• Peritonitis


  Inflammation of the peritoneum, the serous membrane lining the abdominal cavity and covering the viscera
• Most common bacteria implicated in peritonitis

  • Escherichia coli
  • Klebsiella
  • Proteus
  • Pseudomonas
  • Streptococcus species
• Types of peritonitis


  • Primary peritonitis (spontaneous bacterial peritonitis)
  • Secondary peritonitis
  • Tertiary peritonitis
• Clinical manifestations of peritonitis

  • Constant, localized abdominal pain
  • Extremely tender and distended abdomen
  • Rigid muscles
  • Rebound tenderness
  • Anorexia
  • Nausea
  • Vomiting
  • Diminished peristalsis
  • Paralytic ileus
  • Temperature of 37.8°C to 38.3°C (100°F to 101°F)
  • Increased pulse rate
  • Hypotensive

  
• Appendicitis


  Inflammation of the appendix, a small, vermiform (wormlike) appendage attached to the cecum just below the ileocecal valve

  
• Appendicitis is the most frequent cause of acute abdomen
• Incidence of appendicitis is slightly higher among males
• Clinical manifestations of appendicitis

  • Vague periumbilical pain
  • Anorexia
  • Nausea
  • Low-grade fever
  • Local tenderness (McBurney point)
  • Rebound tenderness
  • Rovsing sign
  • Constipation

  
• Clinical manifestations when the appendix has ruptured

  • Consistent pain
  • Abdominal distention
  • Paralytic ileus
• Complications of appendicitis


  • Peritonitis
  • Abscess formation
  • Portal pylephlebitis
  • Septic thrombosis
  • Perforation

  
• Nursing management for a patient with appendicitis

  • Preventing fluid volume deficit
  • Reducing anxiety
  • Preventing or treating surgical site infection
  • Preventing atelectasis
  • Maintaining skin integrity
  • Attaining optimal nutrition
• Care for a patient preparing for appendectomy surgery

  • High Fowler position
  • IV infusion
  • Antibiotic therapy
  • Administration of analgesic (parenteral opioid)
  • Monitoring urine output
  • Encouraging ambulation
• Risk factors for diverticular disease

  • Low intake of dietary fiber
  • Obesity
  • History of cigarette smoking
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen (Tylenol)
  • Positive family history
• Clinical manifestations of diverticulosis

  • Chronic constipation sometimes precedes the development
  • Bowel irregularity
  • Diarrhea
  • Nausea
  • Anorexia
  • Bloating or abdominal distention