NCM 116 – MedSurg II (Lecture) Defecography and colonic transit studies -
Module 5: Nursing Care Management of Clients with
Nutrition & Gastro-intestinal Problems (Part II)
DISTURBANCES IN ABSORPTION AND
ELIMINATION
 DISORDER OF INTESTINAL MOTILITY
 FECAL INCONTINENCE
 IRRITABLE BOWEL SYNDROME
 MALABSORPTION SYNDROME
 STRUCTURAL AND OBSTRUCTIVE
BOWEL DISORDERS
 INTESTINAL
 OBSTRUCTION
 DIVERTICULAR DISORDERS
DISORDER OF INTESTINAL MOTILITY
FECAL INCONTINENCE
 involuntary passage of stool from the rectum
 Influencing factors: ability of the rectum to
sense and accommodate stool, the amount and
consistency of stool, the integrity of the anal
sphincters and musculature, and rectal motility
 embarrassing and socially incapacitating
 FECAL INCONTINENCE (Pathophysiology)
 In general, it results from conditions that
interrupt or disrupt the structure or
function of the anorectal unit (Beitz, 2006)
 Causes: trauma (eg, after surgical
procedures -rectum), neurologic disorders
(eg, stroke, multiple sclerosis, diabetic
neuropathy, dementia), inflammation,
infection, chemotherapy, radiation
treatment, fecal impaction, pelvic floor
relaxation, laxative abuse, medications, or
advancing age.
 FECAL INCONTINENCE (Clinical
Manifestations)
 minor soiling, occasional urgency and loss
of control, or complete incontinence
 poor control of flatus, diarrhea, or
constipation.
 ASSESSMENT & DX. FINDINGS
 Flexible sigmoidoscopy - rule out tumors,
inflammation, or fissures
 X-ray studies: barium enema, CT, anorectal
manometry, and transit studies - identify
alterations in intestinal mucosa and muscle
tone or detect structural or functional
problems
 Anorectal manometry (ie, pressure studies
such as a balloon expulsion test) may be
performed to assess malfunction of the
sphincter
assessment of active anorectal function
 Pelvic floor magnetic resonance imaging
(MRI) - identify occult pelvic floor defects
 FECAL INCONTINENCE (Medical
Management)
 no known cure; specific management -
quality of life
 related to diarrhea - disappear when diarrhea
is successfully treated
 frequent symptom of a fecal impaction -
After removal of impaction and the rectum
is cleansed, normal functioning of the
anorectal area can resume
 Biofeedback therapy w/pelvic floor muscle
training - if the problem is decreased
sensory awareness or sphincter control
 Surgical procedures: surgical
reconstruction, artificial sphincter
implantation, sphincter repair, or fecal
diversion
 FECAL INCONTINENCE (Nursing
Management)
 Goal: help patient achieve fecal continence;
manage problem so patient can have
predictable, planned elimination
 suppositories (sometimes)- stimulate the
anal reflex; D/C if regular schedule
achieved
 Bowel regulation: initiate bowel-training
program that involves setting a schedule;
therapeutic use of diet & fiber
o Foods that thicken stool (eg,
applesauce) and fiber products
o (eg, psyllium) help improve continence
 maintain skin integrity, esp. in the
debilitated or elderly patient: incontinence
briefs/ diapers (brief period); meticulous
skin hygiene; use of perineal skin cleansers/
protection products
 If continence not achieved - assist patient
and family to accept and cope with chronic
situation
 Fecal incontinence devices (Flexi Seal
Fecal Management System)
o External devices - special rectal
pouches, called fecal incontinence
collectors (drainable)
o Internal drainage systems - eliminate
fecal skin contact; especially useful
when there is extensive excoriation or
skin breakdown
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IRRITABLE BOWEL SYNDROME (IBS)
 occurs more commonly in women than in men,
and the cause remains unknown
 Factors associated: heredity, psychological stress
or conditions (depression and anxiety), a diet
high in fat and stimulating or irritating foods,
alcohol consumption, and smoking
 IBS (Pathophysiology)
 The change in motility may be related to
neuroendocrine dysregulation, especially if
there are changes in serotonin signaling
 Changes in intestinal motility may also
result from infections or other
inflammatory disorders or vascular or
metabolic disturbances
 Peristaltic waves are affected at specific
segments of the intestine and in the
intensity with which they propel the fecal
matter forward
 No evidence of inflammation or tissue
changes in the intestinal mucosa
 IBS (Clinical Manifestations)
 Primary symptom: alteration in bowel
patterns: constipation, diarrhea, or a
combination of both.
 abdominal pain is sometimes precipitated by
eating and is frequently relieved by
defecation
 bloating, and abdominal distention often
accompany changes in bowel pattern
 IBS (Assessment & Dx. Findings)
 Criteria - recurrent abdominal pain or
discomfort for at least 3 days a month in
the past 3 months, including two or more of
the following:
o (1) improvement with defecation;
o (2) onset associated with change in
frequency of stool; and
o (3) onset associated with change in
appearance (form) of stool
o (Laine & Goldman, 2007; Spiller, 2007).
 Definite diagnosis requires tests that
confirm absence of structural
 or other disorders.
o Stool studies, contrast x-ray studies, and
proctoscopy - to rule out other colon
diseases
o Barium enema and colonoscopy - reveal
spasm, distention, or mucus
accumulation in the intestine
o Manometry and electromyography
(EMG) - study intraluminal pressure
changes generated by spasticity
 IBS (Medical Management)
 Goals: relieve abdominal pain, control
diarrhea or constipation, and reduce stress
 Restriction and then gradual
reintroduction of foods that are possibly
irritating - (eg, beans, caffeinated products,
corn, wheat, dairy lactose, fried foods,
alcohol, spicy foods, aspartame)
 High-fiber diet - help control the diarrhea
and constipation Exercise - reduce anxiety
and increase intestinal motility Stress
reduction or behavior modification program
 Hydrophilic colloids (ie, bulk) and
antidiarrheal agents (eg, loperamide)-
control the diarrhea and fecal urgency
 Anticholinergics or antispasmodics (eg,
propantheline [Pro-Banthine])- decrease
smooth muscle spasm, cramping and
constipation
 Antidepressants - assist in treating
underlying anxiety and depression …
 Tegaserod - increased risks of MI and stroke
 Probiotics (Lactobacillus and
Bifidobacterium) - decrease abdominal
bloating and gas
 Complementary medicine - artichoke leaf
extract, peppermint oil, and caraway oil
 IBS (Nursing Management)
 provide patient and family education
 teach & reinforce good dietary habits (eg,
avoid food triggers)
 keep a symptom and food diary for 1 to 2
weeks
 encouraged patient to eat at regular times
and to chew food slowly and thoroughly
 fluid should not be taken with meals because
this results in abdominal distention
 discourage alcohol use and cigarette
smoking
 stress management - relaxation techniques,
yoga, or exercise
IRRITABLE BOWEL DISEASE
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MALABSORPTION SYNDROME
 Inability of the digestive system to absorb one or
more of the major vitamins (especially A &
B12), minerals (ie, iron and calcium), and
nutrients (ie, carbohydrates, fats, and proteins)
 CATEGORIES:
 Mucosal (transport) disorders causing
generalized malabsorption (eg, celiac sprue,
regional enteritis, radiation enteritis)
 Infectious diseases causing generalized
malabsorption (eg, small bowel bacterial
overgrowth, tropical sprue, Whipple’s
disease)
 Luminal disorders causing malabsorption
(eg, bile acid deficiency, Zollinger-Ellison
syndrome, pancreatic insufficiency)
 Postoperative malabsorption (eg, after
gastric/ intestinal resection)
 Disorders that cause malabsorption of
specific nutrients (eg, disaccharidase
deficiency leading to lactose intolerance)
 MALABSORPTION (ClinicalManifestations)
 Hallmarks: diarrhea or frequent, loose,
bulky, foul-smelling stools that have
increased fat content and are often grayish
 often with associated abdominal distention,
pain, increased flatus, weakness, weight
loss, decreased sense of well-being
 chief result - malnutrition
o manifested by weight loss and other
signs of vitamin and mineral deficiency
(eg, easy bruising, osteoporosis,
anemia)
 untreated - patient becomes weak and
emaciated because of starvation and
dehydration
 Failure to absorb the fat-soluble vitamins A,
D and K causes a corresponding
avitaminosis.
 MALABSORPTION (Assessment & Dx
Tests)
 Stool studies for quantitative and qualitative
fat analysis, lactose tolerance tests, D-
xylose absorption tests, and Schilling tests.
 Hydrogen breath test - if carbohydrate
malabsorption suspected
 Endoscopy with biopsy (best diagnostic
tool)
o Biopsy of the small intestine is
performed to assay enzyme activity or
to identify infection or destruction of
mucosa
 Ultrasound studies, CT scans, and x-ray
findings - reveal pancreatic or intestinal
tumors that may be the cause
 CBC - detect anemia
 Pancreatic function tests - assist in Dx. of
specific disorders
 MALABSORPTION (Medical Management)
 avoid dietary substances that aggravate
malabsorption; supplement lost nutrients
 Common supplements are water-soluble
vitamins (eg, B12, folic acid), fat-soluble
vitamins (ie, A, D, and K), and minerals (eg,
calcium, iron)
 Primary disease - managed surgically or
nonsurgically
 Dietary therapy - aimed at reducing gluten
intake (celiac sprue) Folic acid supplements
- tropical sprue
 Antibiotics (eg, tetracycline [Tetracyn],
ampicillin [Polycillin]) - treatment of
tropical sprue and bacterial overgrowth
syndromes
 Antidiarrheal agents - decrease intestinal
spasms Parenteral fluids - dehydration
treatment
 MALABSORPTION SYNDROME
(Gerontologic Considerations)
 The older patient may have more subtle
symptoms of mal- absorption that may be
extraintestinal, including fatigue and
confusion
 Medical management may include the
administration of corticosteroids, which
may cause a host of adverse effects such as
hypertension, hypokalemia, and mood
changes
 Antibiotics may reduce vitamin K–
producing intestinal flora, resulting in a
prolonged prothrombin time (PT) and
international normalized ratio (INR) if the
patient is concurrently taking warfarin
(Coumadin)
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 
Urinary retention, altered mental status,
or glaucoma may occur as adverse effects
of anticholinergic drug therapy in older Intussusception One part of the
people. intestine slips into
 MALABSORPTION(Nursing Management) another lower part.
 provide patient and family education The intestinal lumen
regarding diet and the use of nutritional narrows.
supplements
Volvulus The bowel twists and
o include information about the risk of
turns on itself,
osteoporosis related to malabsorption of
obstructing the
calcium
intestinal lumen. Gas
 monitor patients with diarrhea for fluid and and fluid accumulate
electrolyte imbalances in the trapped bowel
 conduct ongoing assessments to determine
whether the clinical manifestations related
Hernia The intestine
to the nutritional deficits have abated
protrudes through a
weakened area in the
abdomen muscle or
STRUCTURAL AND OBSTRUCTIVE BOWEL wall.
DISORDERS

INTESTINAL OBSTRUCTION Tumor A tumor in the

 occurs when a blockage interferes with the intestinal wall extends
normal progression of intestinal contents into the lumen; or
through the intestinal tract. outside the intestine
 more common in the small intestine causing pressure on
 large intestine - generally occurs in the sigmoid the intestinal wall.
colon
 CAUSES: mechanical or functional; partial or  FUNCTIONAL INTESTINAL
complete OBSTRUCTION
 severity - depends on the region of the bowel  Functional obstruction - intestine can become
affected, degree to which the lumen is adynamic from an absence of normal nerve
obstructed, and degree to which blood stimulation to intestinal muscle fibers
circulation to the intestine is impeded (Smeltzer  Paralytic ileus - lacking peristalsis; common
et al., 2008) 12 to 36 hours after abdominal surgery
 PROMPT TREATMENT o can result from inflammatory conditions
 MECHANICAL CAUSES OF (e.g., peritonitis), electrolyte disturbances
OBSTRUCTION (e.g., hypokalemia), or adverse drug
effects (e.g., narcotics, cholinergic
CAUSE COURSE OF APPEARANCE blockers).
EVENTS  INTESTINAL OBSTRUCTION
(Pathophysiology & Etiology)
Adhesions Loops of intestine  When the intestinal contents cannot move
adhere to areas that freely, the portion above the obstruction
heal slowly or scar distends whereas the portion below the
after abdominal obstruction is empty.
surgery.The  If the obstruction is complete, no gases or
adhesions cause the feces are expelled rectally.
intestinal loop to kink  Both forward and reverse peristalsis becomes
3-4 days later forceful in an attempt to clear the obstruction.
o Stasis of the accumulating volume and
the violent muscular peristaltic
contractions potentiate the risk for
intestinal rupture

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  Locally, the increased pressure pushes
electrolyte-rich fluid from the intestine and
capillaries into the peritoneal cavity.
 Failure of the mucosa to reabsorb the
secretions contributes to water and
electrolyte imbalances and shock.
 Increasing pressure on the bowel from
severe distention and edema impairs
circulation and leads to necrosis and
eventually gangrene of a portion of the
bowel.
 Perforation of the gangrenous bowel, which
results from pressure against weakened
tissue, causes the intestinal contents to seep
into the peritoneal cavity, resulting in
peritonitis
 INTESTINAL OBSTRUCTION (Assessment
Findings)
 Nausea and abdominal distention
 Vomiting - when obstruction occurs high in
the GIT
 (stomach and small intestine)
o emesis appears to contain bile or fecal
material
 Lower GIT obstruction - vomiting may
occur later/ not 1-2 BM soon after the
intestine has been obstructed severe
intermittent cramps
 Perforation symptoms- sudden, sustained
pain, abdominal distention, and fever
 Functional obstruction- absent bowel
sounds
 Mechanical obstruction, the bowel sounds
usually are high- pitched above the
obstructed area. Pulse and respiratory rates
(elevated). BP falls, and urine output
decrease (shock)
 Large bowel obstruction - symptoms occur
more slowly
o Constipation may be the only symptom
for many days
o Eventually the client experiences
abdominal distention, lower abdominal
cramps and pain.
o Fecal vomiting may occur
o Shock symptoms
 INTESTINAL OBSTRUCTION (Diagnostic
Findings)
 Radiographic study of the abdomen - shows
air and fluid collecting in a segment of the
intestine
 Barium enema (used when the risk of
perforation is low) pinpoints location of the
obstruction.
 Serum electrolytes - low levels of Na, K, Cl
 ABG - Metabolic alkalosis
 CBC - increased WBC count (infection)
 Hct - elevated if dehydration develops
 INTESTINAL OBSTRUCTION (Medical/
Surgical Management)
 NPO
 IV fluids with electrolytes - correct
imbalances; antibiotics (infection)
 Intestinal decompression- relieve intestinal
distention, cramping, and vomiting, and
reduce the potential for intestinal rupture
with peritonitis
o accomplished by suctioning large
amounts of accumulated secretions and
gas through NGT or longer intestinal
tube
 Mechanical obstructions may be treated
during colonoscopy - removing obstructing
polyps or destroying benign tumors with
laser therapy or electrocautery
 Surgery - a section of the obstructed bowel
is removed and then the proximal and distal
sections are reconnected (bowel resection
and anastomosis).
o In some cases, a temporary or
permanent ostomy may be performed.
 INTESTINAL OBSTRUCTION (Nursing
Management)
 Documenting all symptoms and obtaining
detailed information.
 manage pain - maintain patency of
decompression tube; administer prescribed
narcotic analgesics
 maintain fluid balance -prevent deficits
related to fluid shifts and losses from
vomiting
 help the client deal with fear related to
severe, possibly life-threatening symptoms
and an unstable condition
 maintain uninterrupted IVF infusion
monitor urinary output hourly
DIVERTICULAR DISORDERS
 Diverticula are sacs or pouches caused by
herniation of the mucosa through a weakened
portion of the muscular coat of the intestine or
other structure
 can appear anywhere in the GI tract, but appear
most commonly in the colon (sigmoid area), in
people older than 50 years of age
 DIVERTICULOSIS/ DIVERTICULITIS
 Asymptomatic diverticula are called
diverticulosis. When the diverticula
become inflamed, the term diverticulitis is
used.
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 DIVERTICULAR DISORDERS
(Pathophysiology & Etiology)
o low dietary fiber intake (higher
incidence)
o congenital predisposition
o result from weakness in the muscular
coat (aging)
 Diverticula become inflamed when fecal
material is trapped in one or more blind
pouches
 Inflammation causes swelling of the tissue
in the area
o several diverticula in one area: severe
edema - intestinal obstruction
 abscesses form - when inflamed tissue
becomes infected with intestinal bacteria
 swollen tissue - rupture or form a fistular
connection with adjacent organ (bladder)
 DIVERTICULAR DISORDERS (Assessment
Findings)
 Constipation alternating with diarrhea,
flatulence, pain and tenderness in the LLQ,
fever, and rectal bleeding
 palpable mass may be felt in the lower
abdomen
 Bleeding diverticula - maroon
stool/resembling ‘‘currant jelly’’
 Barium enema - shows an irregular mucosal
wall
 Colonoscopy - visualize the areas of
inflammation
 CT scan - generally used first as an
alternative; avoid perforation
 CBC -leukocytosis
 Stool specimen - occult blood
 DIVERTICULAR DISORDERS
(Medical/Surgical Management)
 No symptoms - no treatment
 Avoid foods that contain seeds of any kind
 High-fiber diet supplemented with bran or
prescription of a bulk-forming agent (e.g.,
Metamucil) - helps avoid constipation
 When symptoms occur - diet is temporarily
adjusted to low-residue foods
 Severe inflammation and accompanied by
pain and local tenderness - IVF for several
days; NPO
o As the inflammation subsides with
antibiotic therapy, oral fluids and food
are reintroduced
 Surgery - non responsive to medical
treatment, or if complications (perforation,
intestinal obstruction, or severe bleeding)
occur
o The portion of colon that contains the
diverticula is removed, and the
continuity of the bowel is reestablished
by joining the remaining portions of the
colon
 Continuity of the bowel is restored -
colostomy is closed 3 to 6 weeks later
 DIVERTICULAR DISORDERS (Nursing
Management)
 Take VS - establish a baseline and to
determine if the client is febrile
 examines abdomen - pain, tenderness, and
masses
 explain underlying pathology and rationale
for treatment
 consult the dietitian for teaching - list of
foods to eat and avoid
 surgery - prepare client before surgery and
manages the postoperative care
 Include the following points in the teaching
plan:
o Follow the diet recommended by the
physician( reduce pain and discomfort)
o Bran adds bulk to the diet
o Avoid use of laxatives or enemas -
except when recommended by physician
o Avoid constipation - do not suppress the
urge to defecate
o Drink at least 8 to10 large glasses of
fluid each day.
o Take prescribed medications as directed,
even if symptoms improve.
o Exercise regularly if the current lifestyle
is somewhat inactive.
o If severe pain or blood in the stool
occurs, see a physician immediately.
