NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: GASTROINTESTINAL SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

ULCERATIVE COLITIS: inflammation of mucosa and submucosa of the large intestine. Inflammation leads to ulceration with bleeding. Involved areas are
continuous. Disease is characterized by remissions and exacerbations.

A. Pathophysiology: Currently believed to be an autoimmune disease. The body’s immune system is called on to attack the inner lining of the large intestine, causing inflammation and ulceration. Edema and hyperemia of colonic mucous membrane→ superficial bleeding with increased peristalsis, shallow ulcerations, abscesses; bowel wall thins and shortens and becomes at risk for perforation. Increased rate of flow of liquid ileal contents→ decreased water absorption and diarrhea.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Highest occurrence in young adults (ages 20 to 40 years).
  • Genetic predisposition: higher in whites, Jews.
  • Autoimmune response.
  • Infections.
  • More common in urban areas (upper-middle incomes and higher educational levels).
  • Nonsmokers/ex-smokers.
  • Genetic, inherited, or familial tendencies.
  • Chronic ulcerative colitis is a risk factor for colon cancer.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Urgency to defecate, particularly when standing.

b. Loss of appetite, nausea.

c. Colic-like abdominal pain.

d. History of intolerance to dairy products.

e. Emotional depression.

  • Objective data:

a. Diarrhea: 10 to 20 stools/day; can be chronic or intermittent, episodic or continual; stools contain blood, mucus, and pus.

b. Weight loss and malnutrition, dehydration.

c. Fever.

d. Rectal bleeding.

e. Laboratory data: decreased: RBC count, potassium, sodium, calcium, bicarbonate related to excessive diarrhea.

f. Lymphadenitis.

g. Diagnostic tests:

(1) Sigmoidoscopy/colonoscopy for visualization of lesions.
(2) Barium enema.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Diarrhea related to increased flow rate of ileal contents.
  • Self-esteem disturbance related to progression of disease and increased number and odor of stools.
  • Pain (acute) related to inflammatory process.
  • Fluid volume deficit related to frequent episodes of diarrhea.
  • Knowledge deficit (learning need) related to methods to control symptoms.
  • Social isolation related to continual diarrhea episodes.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent disease progression and complications.

a. Administer medications:

(1) Salicylates: sulfasalazine (Azulfidine), olsalazine (Dipentum), mesalamine (Asacol, Pentasa). All given PO in high doses. Mesalamine (Rowasa) is given in
enema or suppository form.

(2) Corticosteroids: prednisone, PO or

IV. Hydrocortisone (Cortenema) is given by enema.

(3) Immunosuppressants: azathioprine (Imuran), and 6-mercaptopurine (Purinthol), cyclosporine (Sandimmune), and methotrexate (Rheumatrex).

(4) Nicotine.

(5) Sedatives and tranquilizers to produce rest and comfort.

(6) Absorbents: kaolin/pectin (Kaopectate).

(7) Anticholinergics and antispasmotics to relieve cramping and diarrhea: atropine sulfate, phenobarbital, diphenoxylate/ atropine sulfate (Lomotil).

(8) Anti-infective agents to relieve bacterial overgrowth in bowel and limit secondary infections: metronidazole (Flagyl).

(9) Potassium supplements to relieve deficiencies related to excessive diarrhea.

(10) Calcium folate and vitamin B12 when malabsorption is present.

  • Goal: reduce psychological stress.

a. Provide quiet environment.

b. Encourage verbalization of concerns.

  • Goal: health teaching.

a. Diet:

(1) Avoid: coarse-residue, high-fiber foods (e.g., raw fruits and vegetables), whole milk, cold beverages (because of inflammation).
(2) Include: bland, high-protein, high-vitamin, high-mineral, high calorie foods.
(3) Parenteral hyperalimentation for severely ill.
(4) Force fluids by mouth.

b. Monitor for colon cancer, especially 8 to 10 years after incidence.

  • Goal: prepare for surgery if medical regimen unsuccessful.

a. Possible surgical procedures:

(1) Permanent ileostomy (J pouch).

(2) Continent ileostomy (Kock pouch).

(3)Total colectomy, anastomosis with rectum.

(4)Total colectomy, anastomosis with anal sphincter.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Fluid balance is obtained and maintained.
  • Alterations in lifestyle are managed.
  • Stress-management techniques are successful.
  • Complications such as fistulas, obstruction, perforation, and peritonitis are avoided.
  • Client is prepared for surgery if medical regimen is unsuccessful or complications develop.

CROHN’S DISEASE: a chronic inflammatory disease causing ulcerations in the small and large intestines. The immune system seems to react to a
variety of substances and/or bacteria in the intestines, causing inflammation, ulceration, and bowel injury. Called Crohn’s colitis when only large intestine is involved; Crohn’s enteritis when only small intestine is involved; terminal ileitis when lowest part of small intestine is involved; Crohn’s enterocolitis or ileocolitis when both small and large intestines are involved.

A. Pathophysiology: one of two conditions called “inflammatory bowel disease” (ulcerative colitis is the other) that affects all layers of the ileum, the colon, or both, causing patchy, shallow, longitudinal mucosal ulcers; possible correlation with autoimmune disease and adenocarcinoma of the bowel. Small, scattered, shallow crater-like areas cause scarring and stiffness of the bowel → bowel becomes narrow → obstruction, then pain, nausea, and vomiting.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Age: 15 to 20, 55 to 60 years.
  • Whites, especially Jews.
  • Familial predisposition.
  • Possible virus involvement.
  • Possible psychosomatic involvement.
  • Possible hormonal or dietary influences.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Abdominal pain.

b. Anorexia.

c. Nausea.

d. Malaise.

e. History of isolated, intermittent, or recurrent attacks.

  • Objective data:

a. Diarrhea.

b. Weight loss, vomiting.

c. Fever, signs of infection.

d. Fluid/electrolyte imbalances.

e. Malnutrition, malabsorption.

f. Occult blood in feces.

D. Analysis/nursing diagnosis, Nursing care plan/ implementation, Evaluation/outcome criteria

INTESTINAL OBSTRUCTION: blockage in movement of intestinal contents through small or large intestine.

A. Pathophysiology:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Mechanical causes—physical impediments to passage of intestinal contents (e.g., adhesions, hernias, neoplasms, inflammatory bowel disease, foreign bodies, fecal impactions, congenital or radiational strictures, intussusception, or volvulus).
  • Paralytic causes—passageway remains open, but peristalsis ceases (e.g., after abdominal surgery, abdominal trauma, hypokalemia, myocardial infarction, pneumonia, spinal injuries, peritonitis, or vascular insufficiency).

B. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data: pain related to:

a. Proximal loop obstruction: upper abdominal, sharp, cramping, intermittent pain.

b. Distal loop obstruction: poorly localized, cramping pain.

  • Objective data:

a. Bowel sounds: initially loud, high pitched; then when smooth muscle atony occurs, bowel sound absent.

b. Increased peristalsis above level of obstruction in attempt to move intestinal contents through the obstructed area.

c. Obstipation (no passage of gas or stool through obstructed portion of bowel; no reabsorption of fluids).

d. Distention.

e. Vomiting:

(1) Proximal loop obstruction: profuse nonfecal vomiting.
(2) Distal loop obstruction: less frequent fecal-type vomiting.

f. Urinary output: decreased.

g. Temperature: elevated; pulse: tachycardia; BP: hypotension → shock if untreated.

h. Dehydration, hemoconcentration, hypovolemia.

i. Laboratory data:

(1) Leukocytosis.
(2) Decreased: sodium (<138 mEq/L), potassium (<3.5 mEq/L).
(3) Increased: bicarbonate (>26 mEq/L), BUN (>18 mg/dL).
(4) pH: If obstruction is at gastric outlet, pH will be elevated, indicating metabolic alkalosis; if obstruction is distal duodenal or proximal jejunal, the pH will drop and metabolic acidosis occurs.

C. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Fluid volume deficit related to vomiting.
  • Pain related to increased peristalsis above the level of obstruction.
  • Altered nutrition, less than body requirements, related to vomiting.
  • Risk for trauma related to potential perforation.

D. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: obtain and maintain fluid balance.

a. Nursing care of client with nasogastric tube.

(1) Miller-Abbott tube: dual lumen, balloon inflated with air after insertion. Caution: do not tape tube to face until tube reaches point of obstruction.
(2) Cantor tube: has mercury in distal sac, which helps move tube to point of obstruction. Caution: do not tape tube to face until tube reaches point of obstruction.

b. Nothing by mouth, IV therapy, strict I&O.

c. Take daily weights (early morning), monitor CVP for hydration status.

d. Monitor abdominal girth for signs of distention and urinary output for signs of retention or shock.

  • Goal: relieve pain and nausea.

a. Medications as ordered:

(1) Analgesics, antiemetics.
(2) If problem is paralytic: medical treatment includes neostigmine to stimulate peristalsis.

b. Observe for bowel sounds, flatus (tape intestinal tube to face once peristalsis begins).

c. Skin and frequent mouth care.

  • Goal: prevent respiratory complications.

a. Encourage coughing and deep breathing.

b. Semi-Fowler’s or position of comfort.

  • Goal: postoperative nursing care (if treated surgically).

E. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Fluid balance obtained and maintained.
  • Shock prevented.
  • Obstruction resolved.
  • Pain decreased.
  • Fluids tolerated by mouth.
  • Complications such as perforation and peritonitis avoided.

FECAL DIVERSION—stomas: performed because of disease or trauma; may be temporary or permanent.

A. Types (Comparison of Ileostomy and Colostomy).

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Temporary—fecal stream rerouted to allow GI tract to heal or to provide outlet for stool when obstructed.
  • Permanent—intestine cannot be reconnected. Rectum and anal sphincter removed (abdominal perineal resection). Often performed for cancer of the colon and/or rectum.
  • Continent ileostomy—pouch is created inside the wall of the intestine. The pouch serves as a reservoir similar to a rectum. The pouch is emptied on a regular basis with a small tube.
Physiological Integrity: Nursing Care of the Adult Client
  • Ileoanal anastomosis (J pouch, S reservoir, or ileoperistaltic reservoir)—the large intestine is removed and the small intestine is inserted into the rectum and attached just above the anus. The muscles of the rectum remain intact and the normal route of stool elimination is maintained.

B. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Bowel incontinence related to lack of sphincter in newly formed stoma.
  • Altered health maintenance related to knowledge of ostomy care.
  • Body image disturbance related to stoma.
  • Fear related to medical condition requiring stoma.
  • Fluid volume deficit related to increased output through stoma.

C. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Preoperative period:

a. Goal: prepare bowel for surgery.

(1) Administer neomycin as ordered to reduce colonic bacteria.
(2) Administer cathartics, enemas as ordered to cleanse the bowel of feces.
(3) Administer low-residue or liquid diet as ordered.

b. Goal: relieve anxiety and assist in adjustment to surgery.

(1) Provide accurate, brief, and reassuring explanations of procedures; allow time for questions.
(2) Referral: have enterostomal nurse visit to discuss ostomy management and placement of stoma appliance.
(3) Referral: offer opportunity for a visit with an Ostomy Association Visitor.

c. Goal: health teaching.

(1) Determine knowledge of surgery and potential impact.
(2) Begin teaching regarding ostomy.

  • Postoperative period:

a. Goal: maintain fluid balance.

(1) Monitor I&O because large volume of fluid is lost through stoma.
(2) Administer IV fluids as ordered.
(3) Monitor losses through NG tube.

b. Goal: prevent other postoperative complications.

(1) Monitor for signs of intestinal obstruction.
(2) Maintain sterility when changing dressings; avoid fecal contamination of incision.
(3) Observe appearance of stoma: rosy pink, raised (Colostomy sites).

c. Goal: initiate ostomy care.

(1) Protect skin around stoma: use commercial preparation to toughen skin and use protective barrier wafer (Stomahesive) or paste (Karaya or substitute) to keep drainage (which can cause excoriation) off the skin.

(2) Keep skin around stoma clean and dry; empty appliance frequently. Check for drainage in appliance at least twice during each shift. If drainage present (diarrheatype stool):

(a) Unclip bottom of bag.

(b) Drain into bedpan.

(c) Use a squeeze-type bottle filled with warm water to rinse inside of appliance.

(d) Clean clamp, if soiled.

(e) Put a few drops of deodorant in appliance if not odor-proof.

(f) Fasten bottom of appliance securely (fold bag over clamp two or three times before closing).

(g) Check for leakage under appliance every 2 to 4 hours.

(3) Change appliance when drainage leaks around seal, or approximately every 2 to 3 days. Initially, size of stoma will be large due to edema. Pouch opening should be slightly larger than stoma so it will not constrict. Stoma will need to be measured for each change until swelling subsides to ensure appropriate fit.

(a) Gather equipment: gloves, skin prep packet, colostomy appliance measured to fit stoma properly (use stoma measuring guide), skin barrier, warm water and soap, face cloth/towel, plastic bag for disposal of old equipment.
(b) Remove old appliance carefully, pulling from area with least drainage to area with most drainage.
(c) Wash skin area (not stoma) with soap and water. Be careful not to: irritate skin, put soap on stoma, irritate stoma; do not put anything dry onto stoma. Remember: bowel is very fragile; working near bowel increases peristalsis so that feces and flatulence may be expelled.
(d) Observe skin area for potential breakdown.
(e) Use packet of skin prep on the skin around the stoma. Do not put this solution onto stoma, because it will cause irritation. Allow skin prep solution to dry on skin before applying colostomy appliance.
(f) Apply skin barrier you have measured and cut to size.
(g) Put appliance on so that bottom of appliance is easily accessible for emptying (e.g., if client is out of bed most of the time, put the bottom facing the feet; if client is in bed most of the time, have bottom face the side). Picture-frame the adhesive portion of the appliance with 1-inch tape.
(h) Put a few drops of deodorant in appliance if not odor-proof.
(i) Use clamp to fasten bottom of appliance.
(j) Talk to client (or communicate in best way possible during and after procedure). This is a very difficult alteration in body image.
(k) Use good hand-washing technique.

(4) Use deodorizing drops in appliance and provide adequate room ventilation to decrease odors. Caution: deodorizing drops must be safe for mucous membranes. No pinholes in pouch.

(5) If continent ileostomy (a Kock pouch) has been constructed, the client does not have to wear an external pouch. The stool is stored intra-abdominally. The client drains the pouch several times daily, when there is a feeling of fullness, using a catheter. The stoma is flat and on the right side of the abdomen.

d. Goal: promote psychological comfort.

(1) Support client and family—accept feelings and behavior.
(2) Recognize that such a procedure may initiate the grieving process.

e. Goal: health teaching.

(1) Self-care management skills related to ostomy appliance, skin care, and irrigation, if indicated (Colostomy Irrigation*).
(2) Diet: adjustments to control character of feces; avoid foods that increase flatulence.
(3) Signs of complications of infection, obstruction, or electrolyte imbalance.
(4) Community referral for follow-up care.

D. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Demonstrates self-care skill for independent living.
  • Makes dietary adjustments.
  • Ostomy functions well.
  • Adjusts to alteration in bowel elimination pattern.
Physiological Integrity: Nursing Care of the Adult Client
Physiological Integrity: Nursing Care of the Adult Client

HEMORRHOIDS: enlarged vein/veins in mucous membrane of rectum. Hemorrhoids can be internal or external. Bleeding internal hemorrhoids can be painful and are best treated by: rubber band ligation, injection sclerotherapy, infrared coagulation, or surgery (scalpel, cautery, or laser). Laser surgery is usually done on an outpatient basis and causes minimal discomfort. High-fiber diets can minimize constipation and prevent hemorrhoids.

A. Pathophysiology: venous congestion and interference with venous return from hemorrhoidal veins → increase in pelvic pressure, swelling, and distortion.

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Straining to expel constipated stool.
  • Pregnancy.
  • Intra-abdominal or pelvic masses.
  • Interference with portal circulation.
  • Prolonged standing or sitting.
  • History of low-fiber, high-carbohydrate diet, which contributes to constipation.
  • Family history of hemorrhoids.
  • Enlarged prostate.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data: discomfort, anal pruritus, pain.
  • Objective data:

a. Bleeding, especially on defecation.

b. Narrowing of stool.

c. Grapelike clusters around anus (pink, red, or blue).

d. Diagnostic test:

(1) Visualization for external hemorrhoids.
(2) Digital examination or proctoscopy for internal hemorrhoids.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Pain related to defecation.
  • Constipation related to dietary habits and pain at time of defecation.
  • Knowledge deficit (learning need) related to foods to prevent constipation.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: reduce anal discomfort.

a. Sitz baths, as ordered; perineal care to prevent infection.

b. Hot or cold compresses as ordered to reduce inflammation and pruritus.

c. Topical medications as ordered:

(1) Anti-inflammatory: hydrocortisone cream (Anusol).
(2) Astringents: witch hazel–impregnated pads.
(3) Topical anesthetics: pramoxine (Procto- Foam); dibucaine (Nupercainal).

d. Bulk laxatives: psyllium (Metamucil), Konsyl, polycarbophil (FiberCon).

  • Goal: prevent complications related to surgery.

a. Encourage postoperative ambulation.

b. Pain relief until packing removed.

c. Monitor for: bleeding, infection, pulmonary emboli, phlebitis.

d. Facilitate bowel evacuation: stool softeners, laxatives, suppositories, oil enemas as ordered.

e. Monitor for: syncope/vertigo during first postoperative bowel movement.

f. Diet:

(1) Low residue (postoperative)—until healing has begun.
(2) High fiber to prevent constipation after healing.

g. Increase fluid intake.

  • Goal: health teaching—methods to avoid constipation.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • No complications.
  • Client has bowel movement.
  • Incorporates knowledge of correct foods into lifestyle.

FURTHER READING/STUDY:

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