Alteration in Elimination Bowel | Colorectal Cancer | Crohn's Disease

Alteration in elimination: Bowel disease

Alteration in elimination bowel
• Inflammatory bowel disease • Small bowel obstruction

• Cancer of the colon and ostomies.


Large intestine .



Small intestine • Made up of three parts: ileum. jejunum. and duodenum. • Main function is absorption .

Small intestine .



Diarrhea • It is a symptom not a primary disorder. • It is the increase in: fluid. • Causes: – Bacteria toxins – Parasitic infections – Malabsorption syndromes – Medication – Systemic disease – Allergies – Psychogenic . and fluid content of the stool. volume.

. • Most common cause: Ignoring the urge to defecate.Constipation • Two or less BM’s weekly or when defecation is excessively difficult or requires straining. Treat this cause with education ( a daily BM is not necessary for good health) exercise and diet modification.

Nursing assessment • Questions ask? – Have you been out of the country? – What medications have you used? – When did the diarrhea start? – Are there any associated symptoms? .

pus. .Nursing assessment • Observe the patient’s stool for steatorrhea. • Measure abdominal girth and auscultate bowel sounds every shift. blood. • Monitor frequency and characteristics of bowel movement. or mucus.

Nursing diagnosis • Fluid volume deficit • Risk for impaired skin integrity • Altered nutrition: less than body requirements related to loss of nutrients .

skin turgor. – Record Accurate I&O – Weight patient QD – Assess the patient’s mucous membrane. – Monitor and record vital signs including orthostatic blood pressures. . and urine specific gravity.Fluid and electrolyte imbalance r/t diarrhea • The increased water content of the stool places the patient at risk for fluid deficit.

Orthostatic changes indicate fluid deficit. Pulse typically increases at the same time.Fluid and electrolyte imbalance r/t diarrhea • Postural (orthostatic) blood pressure changes. . sitting to standing). • When the BP drops more than 10mmHg when changing positions (lying to sitting.

Use warm water and soft cloths.Risk for impaired skin integrity • Provide good skin care • Assist the client with cleaning the perianal area as needed. • Provide protective ointment to the perianal area .

Caution on pharmacological treatments • Laxatives should never be administer to a patient with bowel obstruction or impaction. . • People with abdominal pain of undetermined cause. • Laxatives can cause mechanical damage and perforate the bowel.

.Caution on pharmacological treatments • Enemas are use for chronic constipation or fecal impaction. • As a general rule use only for acute phase on a short time bases. • Excessive use of enema can lead to fluid electrolyte imbalance. • Never use enemas if you suspect perforation.


Chronic inflammatory bowel disease • Two inflammatory diseases(Crohn’s disease and Ulcerative colitis )similar on the following : • Etiology is unknown (autoimmune component involve) • genetic components/run families/ethnic groups • Affect young adults between the ages 15-35 years. • Diarrhea is the predominant symptom .

hx crohn’s.Ulcerative colitis • Affects the mucous and the submucosa of the colon and rectum. . of the same. • Primarily affects the young (15-30) • More common in whites • Cause unknown found in families with hx. Hx certain arthritis.

Pathophysiology of ulcerative colitis – Inflamed crypts of Lieberkuhn in the distal large intestine and rectum – Pinpoint microscopic hemorrhages develop – Then crypt abscesses develop. – The abscesses penetrated the superficial submucosa an spread laterally leading to mucosal necrosis and sloughing. .

– It bleeds easy and hemorrhage is common. – The mucosa becomes red because of vascular congestion.Pathophysiology of Ulcerative Colitis – The inflammatory process leads to further tissue damage from exudate and the release of inflammatory mediators such as prostanglandins and cytokines. . friable and edematous.

– Chronic inflammation leads to shortening of the colon from fibrosis and loss of haustra. – Pseudopolyps tongue line projections are common.Pathophysiology of Ulcerative Colitis – Edema obscure the submucosal vessels and creates a granular appearance. – Polypoid changes represent areas of edematous tissue between areas of ulceration .. .

Pathophysiology of Ulcerative Colitis – The inflammatory process begins at the rectosigmoid are of the anal canal and progresses proximal. – May progress to involve the entire colon. – Blood. mucus and pus pool in he lumen of the colon (characteristic diarrhea) – The extent of the colon involving correlates with severity of the disease. .

Polyps changes that occur in ulcerative colitis .

Ulcerative colitis .

Ulcerative Colitis signs and symptoms • • • • Insidious onset Attacks last 1-3 months Occur at intervals of months to years Diarrhea is the predominant symptoms of all types of ulcerative colitis. . • Typically 30-40 stools per day. with blood and mucus.

thromboemboli. . lesions of the liver. uveitis. – Patients with Ulcerative Colitis have an increased risk of developing colon cancer.Ulcerative Colitis signs and symptoms – When severe disease is present may have other manifestation such as arthritis (related to the inflammatory process going on). gallbladder. and pancreas as well as pericarditis.

– The risk is higher when there is intensive involvement of the colon with disease for >10 years. .Complications of Ulcerative Colitis – Bowel perforation most deadly – Hemorrhage – Toxic megacolon – Increased risk of developing colon cancer.

.Diagnostic of Ulcerative Colitis – Stool for occult blood – Hemoglobin and hematocrit – Colonoscopy**not on active phase – Barium enema**” – A yearly colonoscopy is strongly recommended for anyone who has ulcerative colitis with 8-10years after the DX.

Treatment of Ulcerative Colitis • Pharmacological • Dietary management • Surgical management .

. • Mesalamine (Rowasa) & Olsalazine (Dipentum) -Same action as above. • Corticosteroids-anti-inflammatory effects – Use as a treatment during acute attacks.Pharmacological treatment • Sulfasalazine (Azulfidine) anti-inflamatory – inhibits prostaglandin production in the bowel.

Pharmacological treatment • Immunossupression – Imuran (Azathioprine) – Cyclosprine (Sandimmune) • Antidiarrheal (not used during an acute attack) – Loperamide – Diphenoxylate .

Dietary management in ulcerative colitis – No milk products – No caffeine – No gas producing or raw fruits & vegetables – Bulk forming products such as psyllium or methylcellulose to decreased diarrhea and reduce symptoms. – TPN during acute exacerbation .

Surgery as a treatment for ulcerative colitis. – The entire colon and rectum are remove – A pouch is formed from the terminal ileum . – Procedure of choice is a total colectomy with ileonal anastomosis.

. – The pouch is brought into the pelvis and anastomosed to the anal canal. – When the anastomosis sites heal the ileostomy is closed and the patient has bowel movements through the anus. – A temporary or loop ileostomy is performed and maintained for 2 to 3 months.Surgery as a treatment for ulcerative colitis.

Ileal Pouch reconstruction .

Ileonal anastemosis .

– Stool collects in the pouch until the patient drains it with a catheter – A nipple valve prevent leakage of stool. .Surgery as a treatment for ulcerative colitis. • The Kock’s ileostomy(continent) – an intra-abdominal reservoir is constructed from the terminal ileum.

Continent ileostomies .

rectum. . • Total proctocolectomy with permanent ileostomy.Surgery as a treatment for ulcerative colitis. and anus are remove. – Colon. and the end of the terminal ileum is exteriorized as a stoma on the right abdominal wall.

A healthy appearing stoma .

– When the stoma is not needed a second surgery is done to close the stoma and repair the bowel. • Temporary or loop ileostomy is often used to eliminate feces and allow healing for 2-3 months after an ileoanal anastomosis. . for changing an ostomy pouch. • See Lemone text pp.826-829 for nursing care of patients with an ileostomy. and for ileostomy lavage.Surgery as a treatment for ulcerative colitis. – A loop of the ileum is brought to the body surface and allows stool drainage into the external pouch.


Nursing care in ulcerative colitis • Relieving abdominal cramping • Providing emotional support • Teaching about the illness and special needs. • Nursing diagnosis: – Fluid and electrolytes imbalance R/T diarrhea – Body image disturbance R/T disease process .

wt. for signs of fluid deficit. • Record pt.Fluid and electrolyte imbalance • Monitor the appearance and frequency of bowel movement. • Assess the pt. qd. • Assess and document presence of blood in the stool by testing for occult blood and BRB • Assess document Vital signs q4hrs. • Maintain fluid intake by mouth or by parenteral means as indicated .

• Accept patient feeling and perception of self. • Teach coping strategies. . to make choice and decision regarding care. • Encourage discussion about concerns regarding the effects of the disease on close relationship. in the teaching plans and provide instructions as needed. • Arrange for interaction with group of people with similar problems. • Encourage pt. • Involve pt.Disturbance in Body image • Encourage the patient to discuss physical changes and their consequences.

side effects special consideration. . up care .Teaching tips for patients with ulcerative colitis • Emphasize the need to • If a surgical maintain an intake of 2 intervention is to 3 quarter of fluids planned. teach about per day to compensate the surgery and follow for fluid losses. Contact an ET nurse. • Provide diet teaching refer to dietician if • Discuss medications . needed actions.

• Discuss the use of OTC medications such as enteric coated or time release tablets and the fact that these medications might not be absorbed adequately before elimination through the ileostomy.Teaching tips for patients with ulcerative colitis • Teach about ileostomy • Refer to support care verbal and written groups and make instructions. community referral. .

• Most frequently affects the terminal ileum and right colon. .Crohn’s disease • Primarily affects young people (10-30 years) • Can occur anywhere in the GI tract.

fistula development. • Skip lesions with areas of the bowel that appear normal.Crohn’s disease • Most frequently affects the terminal ileum and the right colon • Full thickness (transmural) disease • Can lead to ulceration. strictures. .

Crohn’s disease • Cause is unknown • Like ulcerative colitis can have arthritis. and ureteral obstruction. thromboembolism. uveitis. . renal calculus. Also the pt can have cystitis. and vascular disorders.

lesions. – Deeper ulcerations. – Fibrotic changes in the bowel cause to thicken and lose of flexibility. . lumen takes on a cobblestone appearance.Pathophysiology of Crohn’s disease – Begins with an aphthoid lesion similar to canker sore in the mucosa and submocosa of the bowel.

Aphtoid lesions of the mucosa .

View of the intestine with Crohn’s .

Late stages of crohn’s .

Manifestations of Crohn’s disease
– Continuous or episodic diarrhea – Stools are liquid or semiformed and typically do not contain blood. – Abdominal pain and tenderness are common – A palpable RLQ mass is often present – Fever, malaise, weight loss, fatigue, and anemia are common.

Complications of Crohn’s Disease
• • • • Intestinal obstruction Abscess Fistula No associated risk of toxic megacolon as with ulcerative colitis.

Management of Crohn’s Disease • • • • • Managing symptoms Controlling the disease process Rest Stress reduction bowel rest .

Management of Crohn’s Disease • Pharmacological support • Sulfasalazine is limited to the large bowel • Mesaline and olsalazine are more effective treating ileal inflammation. – Immunosuppressive agents • Corticosteroid • Mercaptopurine (6 MP. Purinerol) • Imuran (Azathioprine) • Cyclosporin (Sandimmune) .

elemental enteral feeding is helpful – Fiber added to diet if the Dx. – If a pt.Management of Crohn’s Disease • Nutritional support – Well balance diet – Elimination of milk or milk products. – Ensure. shows symptoms of obstruction a low roughage is recommended . Is located in the colon.


Management of Crohn’s Disease • Surgery – Bowel obstruction is the leading cause for surgery – With Crohn’s disease there is increased risk for fistula formation. – With Crohn’s disease. the surgery does not cure as it does with ulcerative colitis. – Crohn’s disease recur 50 to 75% of the time .

• One of the most significant problems patients suffer is alteration in nutrition.Nursing care for Crohn’s disease • The disease is a chronic life long illness and teaching becomes one of the nursing care priorities. protein rich fluid and blood may be lost due to diarrhea. healing. • The nutritional deficiencies can impair growth and development. bone diseases. • In addition. . cause muscle wasting. and electrolyte imbalance. • This disease significantly alter the ability of the bowel to absorb nutrients.

protein.Nursing care for Crohn’s disease • Provide parental • Weight daily • Maintain accurate I &O nutrition if absorption of nutrients is highly • Monitor laboratory impair. studies closely. low • Involve family member fat . • Administer prescribe • Provide a diet high in nutritional supplements. consult. who prepare meal on • Arrange for dietary dietary teaching. calories. and restriction of specially the person milk products . .

Neoplastic Disorders:Polyps and Colorectal Cancer • The large intestine and the rectum are the most common sites of cancer in the digestive tract. .

Most polyps are benign but some have the potential to become malignant.Polyps – Polyps are masses of tissues that arise from the bowel wall and protrude into the lumen. . The risk of malignancy is almost 100% by the age 40. – Familial polyposis is an uncommon disorder characterized by hundreds of adenomatous polyps throughout the large intestine.

Sessile and pendunculated intestinal polyps .

Polyposis .

Symptoms of polyps • Most are asymptomatic • Intermittent painless rectal bleeding • Dark or bright blood .

Diagnostic for polyps • Barium enema • Sigmoscopy • Digital examination • Colonoscopy • Once identify polyps need to be remove because of the risk of malignancy. • They can be remove during colonoscopy using electrocautery snare or hot biopsy forceps passed through the scope .

Nursing implications for Barium Enema • • • • • • Liquid diet a day before procedure Pt. Laxative given after procedure Stools may be white for 1 to 2 days . NPO 8 hours before the procedure Inform consent Administer laxatives if order.


• Conscious sedation is usually used . • Pt. Needs to be NPO 8 hours before procedure.Nursing implications for colonoscopy • Usually a liquid diet is prescribe 2 days before procedure. • Administer or instruct the pt in bowel preparation procedures.

Cathartics for bowel preparation • Magnesium Citrate – Empty stomach follow by a full glass of water.Chill. Give the medication early in the evening so it does not interfere with sleep.give in early evening. – Chill the solution. • Polyethylene Glycol – No food should be consumed 2 to3 hrs prior nor within 2 hours of ingesting the solution. .

fever.Nursing implications for colonoscopy • Inform consent must be sign • Instruct client about procedure – Biopsy – Polyps removed • After the procedure – Report any abdominal pain. rectal bleeding or mucupurulent discharge. – If a polyp is remove avoid heavy lifting for 7 days and avoid high-fiber food for 1 to2 days. chills. .


Diagnostic for polyps • Polyps tend to recur. – Need to follow-up with another colonoscopy in 3 years and then every 5 years if no further polyps are detected. – See the table on p. Polyps are on the list. . 844 of Lemone: The risk factors for colorectal cancer.

Colorectal Cancer
• It is a malignant tumor arising from the epithelial Tissue of the colon or rectum.
• It is the second leading caused of cancer death in Western countries. • In the United states the incident is 5%

Risk of colorectal cancer
• Age >50 years

• Polyps of the colon and or rectum
• Cancer elsewhere in the body • Family Hx of colorectal cancer • Ulcerative Colitis Crohn’s disease

Risk factors for colorectal cancer
• Exposure to radiation

• Immunodeficiency disease
• High fat intake • Low calcium and fiber intake.


stomach etc. .Pathophysiology of colorectal cancer • Nearly all come from adenocarcinomas that develop from adenomas polyps. submocousa and the bowel layers. • Insidious • Undetected. few symptoms • Spread into the entire bowel... then to the liver.

Pathophysiology of colorectal cancer • Slow growth pattern • 5-15 years of growth before symptoms appear. the submucosa and outer bowel layers. • It spread by direct extension to involve the entire bowel circumference. .

Manifestations of bowel cancer • Bleeding • Changes in bowel habits • Pain. . weight loss (late sign) • Palpable abdominal or rectal mass might be present. anorexia. • Anemia caused from occult bleeding.

.Prognosis – Prognosis depends on the stage of the disease at the time of the diagnosis and on the initiation of treatments.

Primary complications of bowel cancer • Bowel obstruction (narrow lumen) cause by tumor or lesions. • Direct extension of the tumor to adjacent organs . • Bowel perforation ( of the wall by the tumor)allowing contamination of the peritoneal cavity with bowel content.

• The American cancer society recommends screening for early detection of the disease. . • Annual digital rectal examination for all people over age 40. • Annual guaiac testing for occult fecal blood for people over 50.Laboratories and diagnostic for colorectal cancer • Colorectal cancer is a silent disease and treatment in the early stages has high cure rate. • Flexible sigmoidoscopy every 3 to 5 years for any body over the age of 50.

Laboratories and diagnostic for colorectal cancer • CBC • Barium enema • Blood chemistry • Computed topography (CT) • Endoscopy(colonoscopy. sigmoidoscopy ) • Tissue biopsy • Chest x-ray .

Treatment of bowel cancer is surgery • Treatment of bowel cancer is surgery • Chemotherapy (adjunct) and radiation (adjunct) .

– The heat destroy small tumors and it is palliative for large tumors causing obstruction. – Incision can be used to remove a disk of rectum containing tumor with pts. . – Fulguration is used to decreased the size of large tumors. Small well differentiate polyps. – Incision and fulguration are performed during endoscopy eliminating the need for surgery.Treatment of bowel cancer is surgery – Laser photocoagulation uses a very small intense light to generate heat in tissue towards it is directed.

– The distribution of the regional lymph nodes determine the extend of the resection as these may contain metastatic lesions – Most tumors of the ascending. .Treatment of bowel cancer is surgery – Most of the patients with colorectal cancer undergo surgical resection of the colon with anastomosis of the remaining bowel. descending and sigmoid can be resected. transverse .

• See the critical pathway in(p. and anus are removed through both abdominal and perineal incisions. • A permanent sigmoid colostomy is performed.Surgery/treatment for colorectal cancer – Tumors of the rectum usually are treated as follow: • Abdominal perineal resection • The sigmoid colon. rectum. 849 in Lemone) .

– A colostomy is an ostomy made in the colon. – It can be perform if the bowel is obstructed by the tumor. .Surgery/treatment for colorectal cancer – Surgical resections may be accompanied by a colostomy for diversion of fecal contents. as a temporary measure to promote healing of anastomoses or permanent means of fecal evacuation when the rectum and sigmoid colon have been removed.



Colostomies take the name of the portion of the colon from which they are found .

rectum and anus are remove through abdominal and perineal incisions.Types of colostomies – Sigmoid (most common permanent): the sigmoid colon. . – The anal canal is closed and a stoma formed from the proximal sigmoid colon. – The stoma is located in the left lower quadrant of the abdomen.

– The proximal stoma which is functional. The distal colon is not remove but bypassed. – This temporary colostomy may be temporary or permanent. tumor or inflammation.Types of colostomies – Double -barrel : Two separate stomas are created. diverts fecal flow to the abdominal wall. – The distal portion (mucus fistula) expel mucus from the distal colon. being created for cases of trauma. .







Usually temporary. – See your text book for nursing care of patient with a colostomy pre-and post-op. .Types of colostomies – An emergency procedure used to relieve an intestinal obstruction or perforation is a • Transverse loop colostomy: a loop of the transverse colon is brought out of the abdominal wall and suspended over a plastic rod or bridge which prevents it from back into abdomen.

the inflammation of the colostomy is close and the bowel. healing is require such as • About 3 to 6 months following tumor resection or a temporary colostomy . anastomosis is performed – The distal portion of the colon is left in place and is oversewn for closure.Hartmann procedure – Surgical reconnection or anastomosis of the severe portions of the colon is not done immedially because of the heavy bacterial colonization of the colon – This is a temporary would not allow the colostomy usually done anastomosis to heal when bowel rest or properly. .

or recommended as implantation radiation. adjunct therapy specially for rectal • Radiation reduce the tumors. for colon cancer it is external. recurrences of rectal and pelvic tumors .Radiation therapy • While radiation • Small rectal cancer therapy is not effective may be treated with as a primary treatment intracavitary.

• When radiation and chemotherapy are used in combination after surgery it improves control and survival for patients with stage II and stage III in rectal tumors.Chemotherapy • Chemotherapeutic agents such as oral levamisole and intravenous Flurauracil (5-FU) are used post operative as adjunct therapy for for colorectal cancer. .

Nursing care for colorectal cancer • Nursing care is directed at: – Providing emotional support – Teaching about specific diagnostic procedures . – Instruct in colostomy care • Nursing diagnosis – Pain – Alteration in nutrition – Anticipatory grieving – Risk for sexual dysfunction . pre-op and post-op.

– Usually involves the small bowel • Mechanical obstruction: Scar tissue. hernia tumor • Functional obstruction: Peristalsis problem (paralytic ileus) .Intestinal Obstruction • When the intestinal contens fail to be propelled through the lumen of the bowel.

Causes of intestinal obstruction – Adhesions – Incarcerated Hernia – Volvulus – Foreign bodies – Stricture – Inflammatory bowel disease(ulcerative colitis). .

hemorrhage. or perforation of an organ. .Paralytic ileus • Paralytic ileus an impair in the propulsion or forward movement of bowel content. peritonitis. It can be cause by: – GI surgery – Irritation of the bowel due to inflammation. – Hypokalemia – Effects of narcotics or antidiarrhea medications.

. – Lumen of bowel distends – Swallowed air and gases contributed to further distention.What happens in a small obstruction • Obstruction occurs – Gas fluid collect in the area of the bowel proximal.

What happens in a small obstruction • Endotoxins and prostanglandins are released • Large quantities of fluid and electrolytes are drawn into the area. • Further distension occur .

further reduction in motility occurs.What happens in a small obstruction • Cycle of intestinal distention. water and sodium and potassium. • Large volume of fluid trapped in the bowel lead to hypovolemic and shock. • The danger is all of this lead to pressure distention and necrosis of the bowel. .

(becomes feculent with low or distal obstructions) – Visible peristalsis waves .Signs and symptoms of intestinal obstruction (small bowel) – Cramping or colicky abdominal pain intermittent or increasing in intensity. – Vomiting with both high and low obstructions.

• Vomiting with both high and low obstructions.Signs and symptoms of intestinal obstruction (small bowel) • Cramping or colicky abdominal pain intermittent or increasing in intensity. (becomes feculent with low or distal obstructions) • Visible peristalsis waves .

Signs and symptoms of intestinal obstruction (small bowel) • Signs of fluid and electrolytes imbalance • Dehydration • Fever • Later the bowel becomes silent (absent bowel sounds) .

Laboratory and Diagnostic Test • Abdominal x-ray • Bowel contrast x-ray studies(gastrografin) • WBC count is often elevated • Hemoglobin and hematocrit elevated • Serum osmolality is increased • Decreased K+ and CL- .

. – Surgery • NGT put in to prevent vomiting and abdominal distention and prevent aspiration of abdominal content. Fluid and electrolytes deficit need to be corrected before surgery.Management of small bowel obstruction • Gastrointestinal decompression • 90% of partial bowel obstructions are success fully treated with gastrointestinal decompression.

Goals of surgical intervention – Relieve colonic distention – Prevent perforation – Remove obstruction .



Cantor tube use for abdominal decompression .

Frequent complications with bowel obstructions • Fluid electrolytes imbalance • Acid base imbalance • Hypovolemic shock • Perforation/peritonitis .

Nursing diagnosis • Alteration in tissue perfusion/Gastrointestinal • Fluid volume deficit • Ineffective breathing pattern .

– – – – Monitor V.Alteration in tissue perfusion/gastrointestinal • The same obstruction of the bowel lumen may reduce or block the blood supply to the bowel wall. . S Monitor I & O Assess level pain frequently Keep NPO until peristalsis return.

and Nasogastric suction the patient with bowel obstruction usually has problems in this area.Fluid volume deficit • Large collection of fluid in the bowel proximal to the obstruction. – Monitor V.S – Accurate intake and output/ replace with IVF – Measure abdominal girth every 4 hrs. the accompanied vomiting. .

– Vomiting is a late signs if it happens at all – Abdomen is distended with high pitch bowel sounds. .Symptoms of intestinal obstruction (large bowel) – Less common than small bowel obstruction – Constipation and abdominal pain are the more common signs and symptoms.

bowel obstructions occur in the sigmoid segment.Large bowel obstruction • A barium enema is • Most common cause is used to confirm a large cancer of the bowel. bowel obstruction and determined its • Gangrene and location. . perforation is the most common potential • Most common large complications.

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