Management of Patients with Gastrointestinal Disorders

Topic Outline
1. Gastroesophageal Reflux disease
2. Hiatal Hernia
3. Peptic Ulcer Disease
4. Gastric Cancer
5. Appendicitis
6. Peritonitis
7. Diverticulitis
8. Ulcerative Colitis
9. Regional Enteritis
10. Colorectal Cancer
11. Hemorrhoids

Learning Objectives
After studying this topic, you will be able to:
• Describe the various conditions of the esophagus and their clinical manifestations and management.
• Describe the etiology, clinical manifestations, and management of peptic ulcer disease
• Use the nursing process as a framework for the care of patients with gastric and colorectal cancer.
• Use the nursing process as a framework for the care of patients with diverticular disease.
• Compare Crohn’s disease (regional enteritis) and ulcerative colitis about their pathophysiology; clinical
manifestations; diagnostic evaluation; and medical, surgical, and nursing management.
• Describe the nursing management of the patient with an anorectal condition.

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Introduction
Millions of people are affected by gastrointestinal disorders that significantly cause global morbidity and
mortality that have a direct or indirect economic impact, in addition to decreased quality of life. In all age groups,
a fast-paced lifestyle, high levels of stress, irregular eating habits, insufficient intake of fiber and water, and lack
of daily exercise contribute to GI disorders. There is a growing understanding of the biopsychosocial implications
of GI disease. That is, the mind and emotions can have a profound impact on the GI system. Therefore, nurses
can have an impact on these GI disorders by identifying behavior patterns that put patients at risk, educating the
public about prevention and management, and helping those affected to improve their condition and prevent
complications.

Pre-lecture Quiz
True or False: Write T if the statement is True and F if the statement is False
1. Most peptic ulcers result from infection with the gram-negative bacteria H. pylori, which may be acquired
through ingestion of food and water.
2. The vast majority of gastric cancers are acquired and not inherited.
3. The most common site for a peptic ulcer formation is in the pylorus.
4. The patient with irritable bowel syndrome (IBS) should select foods low in fiber to minimize intestinal
irritation.
5. Diverticula may occur anywhere in the small intestine or colon, but most commonly occur in the ascending
colon.

Fill-in-the-Blanks: Read each statement carefully then write the best response on the space provided.
1. ________ is the most common symptom of esophageal disease and may vary from an uncomfortable
feeling in the upper esophagus to acute pain on swallowing.
2. Currently, the most commonly used therapy for peptic ulcers is a combination of ____________, proton,
and pump inhibitors that suppresses or eradicates H. pylori.
3. Straining at stool initiates the ____________ maneuver that results in a potentially dangerous increase
in BP.
4. ________________, the most common cause of acute surgical abdomen in the United States, is the most
common reason for emergency abdominal surgery.
5. In Crohn’s disease, the common clinical manifestations include abdominal pain and _____________.

Fill-in-the-Blank: 1. Dysphagia; 2. Antibiotics; 3. Valsalva; 4. Appendicitis; 5. Diarrhea

Key Answer to Pre-assessment: T/F: 1. True; 2 True; 3. False; 4. False; 5. False;

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 GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Backflow of gastric content in the esophagus and sometimes further back into the mouth and lungs due
to incompetent lower esophageal sphincter.

Etiology: Incompetent lower esophageal sphincter (LES) and Impaired gastric emptying from gastroparesis or
partial gastric outlet obstruction.

Pathophysiology
Incompetent LES (cardiac sphincter)
↓
Gastric contents reflux (flow backward) through the LES into the esophagus.
↓
The acidity of gastric content and amount of time in contact with esophageal mucosa causes mucosal damage
↓
Inflammation and ulceration of the esophagus
↓
Esophagitis
Clinical Manifestations
1. Regurgitation (reflux) of sour or bitter gastric contents into the mouth → nausea & vomiting
2. Pyrosis (heartburn)
3. Odynophagia (sharp substernal pain on swallowing)
4. Globus (sensation of something in the throat)
5. Mild epigastric pain
6. Dyspepsia

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Diagnostic Evaluation
1. Patient history of typical symptoms
2. Endoscopy can visualize inflammation, lesions, or erosions.
3. Acid perfusion (Bernstein test): onset of symptoms after ingestion of dilute hydrochloric acid and saline is
considered positive. This test differentiates between cardiac and noncardiac chest pain.
o NPO for 6 to 8 hours
o NGT insertion then alternate instillation of NSS and 0.1 % HCL
o (-) for GERD if no pain is experienced; if the pain is experienced (+) for GERD.

Medical Management
1. Antacids to reduce gastric acidity
2. Histamine-2 (H2)-receptor antagonists, such as ranitidine, cimetidine, famotidine, nizatidine to decrease
gastric acid secretions.
3. Proton-pump inhibitors such as omeprazole, esomeprazole, pantoprazole, rabeprazole, or lansoprazole
block gastric acid secretion. Should be taken 30 minutes before a meal for optimal control of gastric acidity

Surgical Management: Nissen Fundoplication-mobilization of the lower end of the esophagus and plication (folding)
of the fundus of the stomach around it, creating a tight LES

Nursing Management
1. Position: a) Head of bed elevated 6 to 8 inches; b) Head elevated prone position
2. Provide small frequent thickened feedings.
3. Do not lie down for 2 to 3 hours after eating
4. Bland diet: avoid stimulants, milk, spicy foods, carbonated beverages, garlic, onion, peppermint, fatty
foods, chocolate, coffee, and citrus juices.
5. No tight-fitting clothes
6. Lifestyle modifications: weight reduction (if overweight), smoking cessation, and reduce alcohol.

HIATAL HERNIA
The upper portion of the stomach herniates (protrudes) into the esophageal hiatus of the diaphragm and
into the thoracic cavity when intra-abdominal pressure increases.

Types of Hiatal hernias

1. Sliding hernia: The stomach and gastroesophageal junction slip up into the chest (most common).
2. Paraesophageal hernia (rolling hernia): Part of the greater curvature of the stomach rolls through the
diaphragmatic defect.

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Etiology: muscle weakening due to aging or other conditions, such as esophageal carcinoma or trauma.

Clinical Manifestations
1. Pyrosis (with or without regurgitation of gastric contents into the mouth).
2. Odynophagia
3. Sense of fullness after eating
4. Nocturnal dyspnea

Diagnostic Evaluation
1. Barium study of the esophagus outlines hernia.
2. Endoscopic examination visualizes defect.

Medical Management
1. Antacid therapy to neutralize gastric acid.
2. H2-receptor antagonist (cimetidine, ranitidine) if the patient has esophagitis.
3. Surgical repair of hernia if symptoms are severe.

Nursing Management
1. Elevation of the head of the bed (6 to 8 inches) to reduce nighttime reflux
2. Provide a small frequent meal
3. Maintain upright position at least 1 hour after meals
4. Diet: avoid spicy, fatty foods, and caffeinated beverages
5. Avoid alcohol & tobacco
6. Avoid coughing, bending from the waist, and/or wearing tight-fitting clothes.

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PEPTIC ULCER
Excavation in the mucosal wall and underlying tissues of the esophagus, stomach, pylorus, or the
duodenum

Predisposing Factors
1. Infection: Helicobacter pylori
2. Cigarette smoking - contains nicotine that stimulates increased hydrochloric acid and causes
vasoconstriction.
3. Alcohol - irritates GI mucosa, cause vasoconstriction, and increases gastric acid secretion
4. Caffeine – stimulates increase production of HCl and causes vasoconstriction
5. Drugs (ulcerogenic drugs such as glucocorticoids or NSAIDs, ASA)
6. Gastritis – leads to increased HCl secretion and mucous ulceration
7. Stress – sympathetic nervous system (SNS) is triggered initially in response to stress. However, if stress
is prolonged, SNS is exhausted and parasympathetic (PNS) is activated.
8. Zollinger-Ellison Syndrome: a pancreatic tumor (gastrinoma) → Gastrin secretion → HCL secretion →
Multiple areas of ulceration
9. Irregular, hurried meals
10. Fatty, spicy, highly acidic foods – stimulates HCl production and irritates GI mucosa
11. Type “A” personality (stress personality)
12. Family History (genetics)

Pathophysiology

Excessive secretion of HCL acid in relation to the protective effects of mucus secretion and acid neutralization
↓
Damage to the mucous membrane
↓
Peptic ulcer Disease
Clinical Manifestations
1. Gastric
a. Pain occurring in the epigastric area radiating to the left side of the abdomen.
b. Pain occurs approximately ½ -2 hours after eating.
c. Pain or discomfort continuous in the daytime.
d. Pain is relieved after ingesting antacids.
e. Weight loss
f. Nausea and vomiting and hematemesis

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 2. Duodenal
a. Pain occurring in the epigastric area radiating to the right side of the abdomen.
b. Pain occurs 2-3 hours after meals
c. Intermittent pain that occurs frequently at night
d. Pain increase by fatty foods, but is relieved by other foods.
e. Weight gain
f. Melena

Diagnostic Evaluation
1. Upper gastrointestinal endoscopy
2. Upper GI radiographic examination (barium study).
3. Serial stool specimen to detect occult blood
4. Gastric secretory studies
5. Serology to test for H. pylori antibodies or stool test to assess for H. pylori antigen.

General Measures
1. Eliminate the use of NSAIDs or other causative drugs.
2. Eliminate cigarette smoking (impairs healing).
3. A well-balanced diet with meals at regular intervals. Avoid dietary irritants.

Medical Management
1. Specific Pharmacotherapy
a. Acid-neutralizing agent (antacids): neutralize HCL
o Best taken 1-2-hour after eating since it is the peak time of HCL production
o E.g. Magnesium & aluminum hydroxide (Maalox); Aluminum hydroxide (Amphogel);

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Magnesium hydroxide (Milk of Magnesia)
b. Histamine receptor antagonists: reduce HCL secretion produced by the stomach by blocking the
action of histamine in histamine receptors of parietal cells in the stomach
o Best taken in the morning and at bedtime since food may delay the rate of absorption of
the medication.
o E.g. Cimetidine (Tagamet); Ranitidine (Zantac); Famotidine (Pepcid)
c. Cytoprotective drug: coats ulcer surface by forming a barrier
o Taken 30-60 min before meals
o E.g. Sucralfate (Carafate)
d. Prostaglandin analog: prostaglandin having antisecretory and cytoprotective effects. It also
increases mucous production & bicarbonate level
o Taken with meals
o E.g. Misoprostol (Cytotec)
e. Antisecretory (Proton pump inhibitors of gastric acid): inhibits the production of gastric acid by
slowing the hydrogen-potassium adenosine triphosphatase (H+, K+-ATPase) pump on the surface
of the parietal cells of the stomach. Can heal ulcers quickly- in 4-8 weeks.
o E.g. Omeprazole (Losec); Lansoprazole (Prevacid); Esomeprazole (Nexium)
2. Antibiotics: amoxicillin; clarithromycin; metronidazole; tetracycline for 10 to 14 days to eradicate the
bacteria.
3. Counseling to help cope with a stressful lifestyle.
4. Sedatives/ tranquilizers for a patient with gastric ulcers, to provide rest and relaxation
5. Fluids, electrolytes, blood needs monitored and replaced.
6. Dietary management.

Surgical Management: indicated for hemorrhage, perforation, and acid reduction

1. Vagotomy: resection of the vagus nerve to eliminate the impulses that stimulate HCL secretion.
➢ Decrease HCL secretion and gastric motility.
2. Pyloroplasty: surgical dilation of the pyloric sphincter wherein a longitudinal incision is made in the pylorus,
and it is closed transversely to permit the muscle to relax and to establish an enlarged outlet.
➢ Improves gastric emptying of the acidic chyme.
3. Antrectomy: removal of the pyloric (antrum) portion of the stomach with anastomosis (surgical
connection) to the duodenum (gastroduodenostomy or Billroth I) or anastomosis to the jejunum
(gastrojejunostomy or Billroth II).
a. Billroth I (Gastroduodenostomy): partial gastrectomy with the removal of antrum and pylorus of
the stomach then the gastric stump is anastomosed with the duodenum.

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 b.
Billroth II (Gastrojejunostomy): partial gastrectomy with the removal of antrum and pylorus of
the stomach then the gastric stump is anastomosed with the jejunum.
4. Subtotal Gastrectomy: removal of 75 % of the distal stomach with Billroth I or II repair.
Complications
1. Hemorrhage
a. Monitor for bright red blood or coffee-ground material.
b. Observe for melena
2. Perforation
a. Monitor for acute upper abdominal pain, guarding, rebound tenderness, absent bowel sounds.

Nursing Assessment
1. Determine the location, character, and radiation of pain, factors aggravating or relieving pain, how long it
last, when it occurs.
2. Ask about eating patterns, regularity, and types of food.
3. Take the social history of alcohol consumption and smoking
4. Ask about medications

Nursing Diagnoses
1. Potential for fluid volume deficit secondary to hemorrhage
2. Pain related to epigastric distress secondary to hypersecretion of acid, mucosal erosion, or perforation.
3. Altered nutrition less than body requirements related to the disease process.
4. Knowledge deficit of physical, dietary, and pharmacology treatment.

Nursing Intervention
1. Avoiding fluid volume deficit

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a. Monitor intake and output continuously to determine fluid volume status.
b. Monitor stools for blood and emesis.
c. Monitor hemoglobin and hematocrit and electrolytes.
d. Administer prescribed IV fluids and blood replacement, as prescribed.
2. Relieving pain
a. Take prescribed medication as ordered.
b. Encourage bed rest
c. Provide small, frequent meals to prevent gastric distention if not NPO.
d. Advise the patient about the irritating effects of certain drugs and foods.
3. Providing adequate nutrition
a. Eliminate foods that cause pain or distress; otherwise, the diet is usually not restricted.
b. Eating a small, frequent, bland diet during exacerbation.
c. Provide meals on time.
d. Eat slowly and chew food properly.
e. Avoid the following:
o Fatty foods
o Coffee and other caffeinated drinks and beverages.
o Spices, red/ black pepper
o Large quantities of milk
o Bedtime snacks
4. Patient education
a. Teach the patient the signs and symptoms of bleeding and when to notify the health care provider.
b. Healthy lifestyle changes include adequate nutrition, cessation of smoking, decreased alcohol
consumption, and stress reduction strategies.

GASTRIC CANCER
Malignant tumor of the stomach that commonly occurs in middle-aged males

Predisposing Factors
1. Excessive intake of nitrate-cured, salt-cured, and smoke-cured foods.
2. Cigarette smoking
3. Chronic achlorhydria (absence of hydrochloric acid in the stomach)
4. (+) Family history
5. Diet low in a quantity of vegetable and fruits

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Clinical Manifestations
1. Early Manifestations
a. Typically, the patient presents with the same symptoms as gastric ulcer.
b. Progressive anorexia (loss of appetite)
c. A noticeable change in, or appearance of gastrointestinal symptoms like gastric fullness, dyspepsia
lasting for 4 weeks
d. Blood in the stool
e. Vomiting, that may indicate pyloric obstruction or cardiac orifice obstruction. Occasionally,
vomiting has a coffee-ground appearance because of slow leaks of blood from ulceration of cancer.
2. Later Manifestations
a. Pain is a late symptom
b. Weight loss, loss of strength, anemia, metastasis (usually to the liver), hemorrhage & obstruction.
c. Palpable abdominal mass

Diagnostic Evaluation
1. History – weight loss and loss of strength over several months
2. Upper GI radiography and fiber optic endoscopy

Management: the only successful treatment of gastric cancer is surgical removal (subtotal/total gastrectomy).

Nursing Management
1. Offer client every opportunity to verbalized fears
2. Modify diet to include smaller, more frequent meals of non-irritating foods.
3. Injection of Vitamin B12 will be required for total gastrectomy to prevent surgically induced pernicious
anemia.

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4. Administration of analgesics agents as prescribed and non-pharmacologic methods for pain relief.
5. Instruct on measures to prevent dumping syndrome.

Dumping Syndrome: a complex reaction, which may occur because of excessively rapidly emptying of gastric
contents into the intestine following gastric resection (partial gastrectomy and gastrojejunostomy)

Pathophysiology
Rapid emptying of hypertonic food (bolus) content from the remaining stomach to duodenum or jejunum
→ hypertonic intestinal content draws the extracellular fluid from the bloodstream in jejunum to dilute → decrease
blood volume → shock-like manifestations.

Clinical Manifestations
1. Nausea 5. Syncope
2. Weakness 6. Diarrhea
3. Diaphoresis 7. Hypoglycemia
4. Palpitation/tachycardia

Management
1. Eat small, frequent meals rather than three large meals.
2. Suggest a diet high in protein and low in carbohydrates, and avoid meals high in sugars, milk, and
chocolate.
3. Reduce fluids with meals, but take them between meals.
4. Take anticholinergic medication before meals if prescribe to lessen gastrointestinal activity like dicyclomine
HCl (Bentyl, Antispas); propantheline bromide (Pro-Banthine)
5. Relax when eating; eat slowly and regularly.
6. Lie down and take a rest after meals.
7. Place the patient on the left side-lying after meals.

APPENDICITIS
Inflammation of the vermiform appendix

Etiology: obstruction of the appendix lumen, which can result from fecaliths, foreign bodies, tumors, lymphoid
hyperplasia, or by kinking of the appendix may impair the circulation and lower the resistance.

Incidence: it affects males more than females; the peak incidence is between 10–30 years old (adolescents or
young adults).

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Pathophysiology
Obstruction of the appendix lumen
↓
Inflammatory process that can lead to edema
↓
Bacterial invasion (infection) → Abscess
↓
Increased intraluminal pressure that initiates pain
↓
Ischemia then necrosis (gangrene)
↓
Rupture or perforation → peritonitis

Clinical Manifestations
1. Abdominal pain in the periumbilical area, and the upper right abdomen, moving to the right lower quadrant
(Mc Burney’s point) after 6-12 hours and intensity increases.
2. Anorexia, nausea, and vomiting.
3. Board-like rigidity in Mc Burney’s point with increasing tenderness.
4. Fever (38-38.5 C)
5. Rebound Tenderness (Blumberg sign): production or intensification of pain when pressure is released
6. Rovsing’s sign: palpating the left lower quadrant causes pain on the right lower quadrant
7. Psoas sign: pain that occurs upon slow extension of the right thigh with the patient lying on the left side.
Inflammation of the psoas muscle in acute appendicitis will increase abdominal pain with this maneuver
8. Obturator sign: pain that occurs with passive internal rotation of the flexed right thigh with the patient
supine.
9. If the appendix has ruptured, the pain becomes more diffuse; abdominal distention develops as a result

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of paralytic ileus, and the patient’s condition worsens.

Diagnostic Evaluation
1. Physical examination is consistent with clinical manifestations.
2. Blood studies: WBC count reveals moderate leukocytosis (12,000 to 16,000/mm3).
3. Abdominal ultrasound or CT scan can visualize the appendix and rule out other conditions

Medical Management
1. Antiemetics
2. Antibiotics to control infection
3. IV therapy to maintain fluids and electrolyte balance
4. Analgesics

Complications: perforation (in 95% of cases), abscess, and peritonitis.

Nursing Diagnoses
1. Acute pain related to an inflamed appendix.
2. Risk for infection related to perforation.

Nursing Management (palliative preoperative management)

1. Relieving Pain
a. Monitor pain level, including location, intensity, pattern.
b. Bed rest and place the patient in a comfortable position to relieve abdominal pain and tension such
as semi-Fowler and knees up.
c. NPO to decrease peristalsis and to allow the stomach to empty before the surgery.
d. Place ice bag to right lower quadrant.
e. Avoid factors that increase peristalsis, thereby preventing rupture of appendicitis like heat
application over the abdomen, laxative, and enema.
2. Preventing Infection
a. Evaluate vital signs frequently.
b. Monitor frequently for signs and symptoms of a worsening condition indicating perforation,
abscess, or peritonitis: increasing severity of pain, tenderness, rigidity, distention, ileus, fever,
malaise, and tachycardia
c. Antibiotic therapy as ordered
d. Prepare the patient for surgery immediately.

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Surgical Management
1. Appendectomy (surgical removal of the appendix). Types:
a. Open appendectomy: makes an incision in Mc Burney’s, pulls the appendix through the incision,
ties off at its base, and removes it.
b. Laparoscopic appendectomy: the surgeon makes a very small incision below the navel and inserts
an instrument laparoscope to enable the doctor to see the appendix. Several tiny incisions more
to allow passage of instruments, which are used to cut and clamp off the appendix.
2. Preoperatively maintain bed rest, NPO status, IV hydration, possible antibiotic prophylaxis, and analgesia.
3. Postoperative Care
a. Flat on bed for 6-8 hours to prevent spinal headache
b. Measures following recovery from anesthesia
i. Maintain Fowler’s position
ii. Maintain NPO until peristalsis return
iii. Give analgesic as needed
iv. Encourage the patient to cough and deep breathe to prevent pulmonary complications and
ambulate the patient after 24 hours to prevent DVT.
v. If appendicitis ruptures, may cause peritonitis; Penrose drain is inserted to drain exudates
from the area; Semi Fowler’s position to promotes drainage and to localize inflammation
within the pelvic area.
c. Ongoing Care
i. Document bowel sounds and the passing of flatus or bowel movements and return of
sensation on the lower extremities.
ii. Watch for surgical complications such as continuing pain or fever, which may indicate an
abscess or wound dehiscence.

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PERITONITIS
Inflammation of the peritoneum that occurs when bacteria gain access into the peritoneum (membrane
lining the abdominal cavity and abdominal organs).
Pathogens: Escherichia coli, Klebsiella, and Proteus

Etiology
1. Leakage of intestinal contents from abdominal organs into the abdominal cavity due to inflammation,
infection, ischemia, or tumor perforation
2. Appendicitis & diverticulitis
3. Perforated ulcer or bowel

Pathophysiology
Abdominal or pelvic organ disease
↓
Bacteria and chemical irritants enter normally sterile peritoneal cavity
↓
Inflammation & edema → Intra-abdominal abscess
↓
Fluid shift to the abdominal cavity
↓
Decrease peristalsis
↓
Bowel distention
↓
Hypovolemia; electrolyte imbalance; dehydration & shock

Clinical Manifestations
1. Abdominal tenderness & pain aggravated by movement
2. Abdominal guarding and rigidity, the patient lies very still, usually with legs drawn up.
3. Rebound tenderness and paralytic ileus
4. Abdominal distention due to accumulation of gas and fluids on the abdomen
5. Nausea and vomiting
6. Fever and elevated WBC
7. With generalized peritonitis, large volumes of fluid may be lost into the abdominal cavity (ascites) which
leads to shallow respirations from abdominal distention and upward displacement of the diaphragm.
8. Signs of early shock: restlessness, tachycardia, tachypnea, hypotension, weakness, pallor, diaphoresis &
oliguria

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Diagnostic Evaluation
1. WBC count to determine if leukocytosis is present (leukopenia if severe).
2. ABG levels may show hypoxemia or metabolic acidosis with respiratory compensation.
3. Peritoneal aspiration (paracentesis) to demonstrate blood, pus, bile, bacteria (Gram stain), amylase.
4. Abdominal x-rays may show free air in the peritoneal cavity, gas and fluid collection in small and large
intestines, generalized bowel dilation, intestinal wall edema.

Medical Management
1. Antibiotic therapy to treat inflammatory conditions preoperatively and postoperatively
2. Intravenous fluids electrolytes & colloid replacement with an isotonic solution; possibly TPN.
3. Analgesics for pain; antiemetics for nausea and vomiting.
4. Peritoneal lavage with warm saline to removed exudates
5. Abdominal paracentesis may be done to remove accumulating fluid.
6. Intestinal intubation and suction to decompress the bowel.
7. Oxygen therapy

Surgical Management: excision, resection, repair, or drainage with peritoneal lavage with warm saline to remove
exudates, and insertion of drainage tube-like Penrose drain, Hemovac, and Jackson Prat to drain exudates from
the area.

Nursing Diagnoses
1. Acute pain related to peritoneal inflammation.
2. Deficient fluid volume related to vomiting and interstitial fluid shift.
3. Imbalanced nutrition: less than body requirements related to GI symptomatology

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Nursing Management
1. Achieving pain relief
a. Bed rest in semi-Fowler’s position before surgery to enable less painful breathing and localize
inflammatory process in the pelvic cavity.
b. After surgery, place the patient in the Fowler position to promote drainage by gravity.
c. Encourage deep breathing to prevent respiratory complication
d. Administer analgesics medication as ordered
2. Maintaining fluid and electrolyte volume
a. Keep the patient NPO to reduce peristalsis.
b. Provide IV fluids to establish adequate fluid intake and to promote adequate urine output, as
prescribed.
c. Monitor vital signs, intake, and output, including the measurement of vomitus and NG drainage.
d. Monitor for signs of hypovolemia: dry mucous membranes, oliguria, postural hypotension,
tachycardia, diminished skin turgor.
3. Achieving Adequate Nutrition
a. Administer TPN, as ordered, to maintain a positive nitrogen balance until the patient can resume
oral diet.
b. Reduce parenteral fluids and give oral food and fluids per order when peristaltic sounds return
(determined by abdominal auscultation) and flatus are passed and the patient has bowel
movements.

DIVERTICULITIS
Inflammation and infection of one or more diverticula caused by trapped material and bacteria.
Diverticula: saclike out-pouching of the lining (mucosa & submucosal layer) of the bowel protruding through the
muscle of the intestinal wall.
Diverticulosis: multiple outpouchings of the mucosal lining of the colon (sigmoid colon-95%)

Predisposing Factor: Low fiber diet

Pathophysiology
Low fecal volume in the colon due to fiber deficient content (compacted or hardened stool causes)
↓
Forceful muscular contraction of the colon to push the stool
↓
Excessive increase of intraluminal pressure during defecation
↓

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Herniation (outpouching) of the mucosa & submucosal layer of the bowel on the weakened muscle of the colonic
wall
↓
Entrapment of the fecal materials & bacteria
↓
Inflammation and infection
↓ ↓
Scaring Abscess, bleeding, perforation, peritonitis

Clinical Manifestations
1. Crampy (L) lower quadrant abdominal pain
2. Chronic constipation with an episode of diarrhea
3. Low-grade Fever
4. Nausea and vomiting
5. Abdominal distention and tenderness due to accumulation of gas and fecal waste
6. Signs and symptoms of peritonitis due to development of abscess or perforation of diverticulitis.

Diagnostic Evaluation
1. Laboratory studies: WBC may show leukocytosis, elevated erythrocyte sedimentation rate (ESR);
hemoglobin/hematocrit may be low with chronic or acute bleeding
2. CT scan with contrast agent is the preferred imaging study because it is the most accurate in correctly
identifying diverticulitis and in staging its severity
3. Sigmoidoscopy/colonoscopy to rule out carcinoma and confirm the diagnosis

Medical Management

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1. Diverticulosis
a. Laxatives: psyllium hydrophilic mucilloid (Metamucil); docusate sodium (Colace) to avoid
constipation for diverticulosis.
b. Antispasmodic agents such as propantheline bromide and oxyphencyclimine (Daricon)
2. Diverticulitis
a. Broad-spectrum antibiotics like ampicillin/sulbactam (Unasyn), ticarcillin/clavulanate (Timentin),
ertapenem (Invanz) for 7 to 10 days
b. Analgesic: meperidine HCL (Demerol), oxycodone (OxyContin)

Surgical Management: Resection and end-to-end anastomosis

Nursing Diagnoses
1. Acute pain related to intestinal discomfort, diarrhea, and/or constipation.
2. Risk for deficient fluid volume related to diarrhea, fluid and electrolyte loss, nausea, and vomiting.
3. Constipation or diarrhea related to the disease process.

Nursing Management
1. Achieving pain relief
a. Observe for signs and location of pain, type, and severity, and intervene when appropriate.
Administer non-opiate analgesics as prescribed (opiates may mask signs of perforation) and
Administer anticholinergics, as prescribed, to decrease colon spasm.
b. Auscultate bowel sounds to monitor bowel motility.
c. Palpate the abdomen to determine rigidity or tenderness because of perforation or peritonitis
2. Maintaining fluid balance
a. Maintain NPO status and NG suction until bowel sounds return
b. Provide IV fluid as directed and prepare for blood transfusion if indicated.
c. Monitor intake and output, including NG aspirate.
d. Report any occult or frank blood in stool, tachycardia, drop in BP, fever, or increased pain.
3. Promoting normal bowel elimination
a. During an acute episode of diverticulitis: NPO → clear liquids → low fiber diet and bland diet
b. For diverticulosis
i. High fiber diet
ii. Increase fluid intake 2.5-3 L/day to promote bowel stimulation
iii. Advise the patient to establish regular bowel habits to promote regular and complete
evacuation.
iv. Avoid nuts and seeds which can be trapped in the diverticula
v. Daily exercise

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10
 INFLAMMATORY BOWEL DISEASE
ULCERATIVE COLITIS
Inflammatory disease of the mucosa & less frequently submucosa of the colon. Typically begins on the
rectum/sigmoid colon & spread upward possibly extending throughout the entire colon

Etiology: Unknown
➢ Possible theories include genetic predisposition; environmental factors (viral or bacterial pathogens,
dietary); immunologic imbalance, or disturbances.
Incidence: most common in young adulthood and middle age, with a peak incidence at ages 20 to 40; more
prevalent whites of Jewish descent; and familial incidence

Pathophysiology
Inflammation of the mucosa
↓
Congestion & edema leads to an extreme friability of the mucosa
↓
Mucosa is shed or cast-off
↓
Ulceration → Bleeding
↓
Abscess →Perforation
Clinical Manifestations
1. Severe diarrhea (10-20 x /day) with blood, mucus & pus → dehydration, weight loss, & fever
2. Tenesmus (painful straining), sense of urgency, and frequency.
3. Abdominal pain & tenderness (LLQ)

NCM-116
4. IDA
5. Increased risk of developing colorectal cancer.

Diagnostic Evaluation
1. Laboratory Tests: fecal analysis positive for blood during active disease; CBC-hemoglobin and hematocrit
may be low because of bleeding; WBC may be increased.
2. Barium enema to assess the extent of disease
3. Proctosigmoidoscopy/colonoscopy findings reveal mucosal erythema and edema, ulcers, and inflammation
that begins distally in the rectum and spreads proximally for variable distances.

Medical Management (Pharmacotherapy)

1. TPN for patients with severe dehydration and excessive diarrhea to rest the intestinal tract and restore
nitrogen balance.
2. Aminosalicylates such as sulfasalazine (Azulfidine) are effective for mild or moderate inflammation
3. Corticosteroids are used to treat severe and fulminant diseases. It can be administered orally (e.g.,
prednisone) in outpatient treatment or parenterally (e.g., hydrocortisone [Solu-Cortef]) in hospitalized
patients.
4. Anti-diarrhea drugs
5. Iron supplements like ferrous sulfate (FeSo4) for chronic bleeding and blood replacement for massive
bleeding

Surgical Management: colectomy with ileorectal anastomosis; total proctocolectomy with permanent end
ileostomy. Ileostomy: an opening in the ileum. The opening (stoma) is brought out through the abdominal wall,
usually the lower section of the abdomen. This stoma becomes the outlet for the discharge of intestinal contents.

Nursing Diagnoses
1. Pain related to the disease process.
2. Altered nutrition less than body requirement related to diarrhea, nausea, and vomiting.
3. Potential for fluid volume deficit related to diarrhea, nausea, and vomiting.
4. Risk for infection related to the disease process and surgical procedures.

Nursing Management
1. Promoting Comfort
a. Bed rest
b. For clients experiencing diarrhea, provide an easily accessible bedpan or commode.

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11
 c.
Provide meticulous skincare to the perianal area and apply protective emollient or ointment
because excoriation is common following severe diarrhea.
d. Administer antidiarrheal drugs as prescribed.
2. Achieving Nutritional Requirements
a. Diet: NPO with TPN to rest the intestinal tract → clear liquid → small frequent meals of bland, low
fiber and fat diet.
b. High protein & carbohydrate diet with supplemental vitamin therapy and iron replacement to
correct malnutrition
c. Avoid milk & dairy products if the patient is lactose intolerant.
3. Maintaining Fluid Balance
a. IVF therapy to replace fluids & electrolytes (K+) as prescribed.
b. Monitor accurate intake and output records
c. Weight the client daily; rapid increase or decrease may relate to fluid imbalance
d. Observe for decreased skin turgor, dry skin, oliguria, decreased temperature, weakness, and
increased hemoglobin, hematocrit, BUN, and specific gravity, all of which are signs of fluid loss
leading to dehydration.
4. Minimizing Infection and Complications
a. Give antibacterial drugs as prescribed.
b. Administer corticosteroids as prescribed.
c. Provide conscientious skincare after severe diarrhea
d. Observe for signs of colonic perforation and hemorrhage—abdominal rigidity, distention,
hypotension, and tachycardia.

REGIONAL ENTERITIS (CROHN’S DISEASE)

A chronic idiopathic inflammatory disease that affects any segment of the GI tract but primarily affects

NCM-116
the terminal ileum, cecum & ascending colon. It is predominantly a transmural disease of the bowel wall

Etiology: Unknown
➢ It is thought to be multifactorial with the following theories: genetic predisposition; environmental
agents, such as infections (viral or bacterial overload) or dietary factors, may trigger the disease;
immunologic imbalance or disturbances.

Incidence: most prevalent between the ages of 20-40; occurs equally in both sexes; highest in Jews; and familial
tendency

Pathophysiology
Segmental & transmural inflammation of the intestine → Ulcer formation → Abscesses and fistulae
↓
Thickening of the bowel wall due to the chronic inflammatory process
↓
Narrowing of the intestine
↓
Stricture and Obstruction → Nausea, vomiting, and bloating or abdominal distention
↓
Malabsorption of food & water → Weight loss

Clinical Management: characterized by exacerbations and remissions

1. Right lower quadrant abdominal pain, cramps, and tenderness. Crampy pain after meals, which then
results in malnutrition, weight loss, and possible anemia (hypochromic and macrocytic).
2. Chronic diarrhea (5-6x/day) usual consistency is soft or semiliquid with mucus, pus, rarely bloody or
steatorrhea (because of malabsorption)
3. Low-grade fever due to acute inflammation, fistulas, and if abscesses are present.
4. Nausea, vomiting and bloating, or abdominal distention

Diagnostic Evaluation
1. CBC may show mild leukocytosis, thrombocytosis, anemia, elevated ESR, hypoalbuminemia.
2. Upper GI and small bowel follow-through barium studies may show the classic “string sign” at the terminal
ileum, which suggests a constriction of an intestinal segment.
3. CT of the abdomen and pelvis is helpful with the diagnosis but is more often used to evaluate complications,
such as abscesses or fistulae.
4. Colonoscopy is the procedure of choice. Typical findings include the presence of skip lesions, cobblestoning,
ulcerations, and rectal sparing.

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12
Medical Management
1. TPN
2. Aminosalicylates (Sulfasalazine [Azulfidine]) to relieve infection and inflammation
3. Corticosteroids to reduce inflammation that can be given orally or by IV line.
4. Anti-diarrhea drugs decrease stool frequency in mild to moderate disease

Surgical Management
1. Segmental bowel resection with anastomosis.
2. Subtotal colectomy with ileorectal anastomosis.
3. Total colectomy with an ileostomy for severe disease in the colon and rectum

Nursing Diagnoses
1. Imbalanced nutrition: less than body requirements related to pain, nausea.
2. Deficient fluid volume related to diarrhea.
3. Chronic pain related to the inflammatory disease of the small intestine.

Nursing Management
1. Achieving Adequate Nutritional Balance
a. Encourage a diet that is low in residue, fiber, and fat and high in calories, protein, and
carbohydrates, with vitamin and mineral supplements.
b. Monitor weight daily.
c. Provide small, frequent feedings to prevent distention.
d. TPN if the patient is debilitated.
2. Maintaining Fluid and Electrolyte Balance
a. Monitor intake and output.

NCM-116
b. Provide fluids, as prescribed, to maintain hydration
c. Monitor stool frequency and consistency.
d. Monitor electrolytes (especially potassium) and acid-base balance because diarrhea can lead to
metabolic acidosis.
e. Watch for cardiac dysrhythmias and muscle weakness because of loss of electrolytes.
3. Controlling Pain
1. Administer medications for control of the inflammatory process, as prescribed.
2. Observe and record changes in pain—frequency, location, characteristics, precipitating events, and
duration.
3. Monitor for distention, increased temperature, hypotension, and rectal bleeding—all signs of
obstruction because of the inflammation.
4. Clean rectal area and apply ointments, as necessary, to decrease discomfort from skin breakdown.
5. Prepare the patient for surgery if the response to medical and drug therapy is unsatisfactory.

Chronic Inflammatory Bowel Disease

Regional Enteritis (Crohn’s Ulcerative colitis

Disease)
Transmural Mucosa and submucosa
Parts commonly Ileum/ascending colon Rectum/descending colon
Affected
Age 20 – 40 years 20- 40 years

Bleeding Usually not; stool with pus and mucus Severe; stool with blood, pus, and mucus
Perianal Common Rare-Mild
Involvement
Fistulas Common Rare
Rectal Involvement 20% 100%
Diarrhea Less severe; 3-5 soft stool/ day Severe; 10-20 watery stool/ day
Abdominal Pain Right Lower Quadrant Left Lower Quadrant
Weight Loss Present Present
Intervention TPN TPN
Corticosteroids, aminosalicylate Corticosteroids, aminosalicylate
(Sulfasalazine [Azulfidine]) (Sulfasalazine [Azulfidine])
Partial or complete colectomy with Proctocolectomy with ileostomy
ileostomy or anastomosis

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13
 COLON OR COLORECTAL CANCER
A malignancy of the colon and rectum characterized by uncontrolled growth of anaplastic cells that tends
to invade surrounding tissue and metastasize to other body sites.

Incidence: the second-highest overall death rate for any type of cancer; males and females are affected equally;
highest incidence occurs in a patient about 50 years of age; potentially curable in 80-90% of patients if early
diagnosed.

Predisposing Factors
1. Age above 40 years
2. Diet: low fiber diet; high in fat and refined carbohydrates
3. Obesity
4. History of chronic constipation
5. History of IBD, familial polyposis, or colon polyps
6. Familial history of colon cancer

Most Common Site: Rectosigmoid area: (70%)

Clinical Manifestations
Ascending (Right) Colon Cancer
1. Change in bowel habits
2. Black, tarry stools or occult blood in the stool → anemia
3. Weakness and weight loss
4. Abdominal pain above the umbilicus

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5. Palpable mass in the right lower quadrant

Distal (Left) Colon/Rectal Cancer

1. Change in bowel habits (constipation or diarrhea because of partial obstruction)
2. Bright, streaked red blood in stool and rectal bleeding → anemia
3. Weakness and weight loss
4. Pencil or ribbon-shaped stool
5. Abdominal pain below the umbilicus
6. Tenesmus (involuntary straining at stool) and sensation of incomplete bowel emptying
7. Palpable mass

Most common symptoms

1. Blood in the stool (usually occult)
2. Partial obstruction causing constipation altering with diarrhea, abdominal pains (crampy), and distention
3. Additional signs: progressive weakness, fatigue, anorexia, weight loss, shortness of breath, anemia, and
pallor.

Guidelines for Early Detection of Colorectal Cancer

1. Digital rectal examination yearly after the age of 40.
2. Occult blood test yearly after age 50.
3. Proctosigmoidoscopy every 5 years after age 50, following 2 negative results of the yearly examination.

Diagnostic Evaluation
1. Fecal immunochemical test replaces the older guaiac-based tests.
2. Flexible sigmoidoscopy or Colonoscopy with biopsy: diagnostic procedure of choice after a strong
suspicious clinical history of abnormal barium enema. CT colonography, also known as virtual colonoscopy,
may be used for screening.
3. Pelvic MRI and endorectal ultrasonography to provide information about cancer penetration and pararectal
lymph nodes.

Management
1. Surgery
a. Hemicolectomy for ascending and transverse colon cancer with anastomosis
b. Abdominoperineal Resection (APR) with permanent end colostomy for rectosigmoid cancer.
i. There are 2 incisions: lower abdomen incision to remove the sigmoid; perineal incision to
remove the rectum.

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14
 ii. Necessitate permanent colostomy
2. Chemotherapy
a. Fluorouracil is the most effective drug for colorectal cancer.
b. A newer drug, irinotecan, is being used in protocols for advanced colorectal cancer
3. Radiotherapy may be used preoperatively to improve the resectability of the tumor and may be used
postoperatively as adjuvant therapy to treat residual disease

Nursing Management

Colonic Surgery
Preoperative care
1. Provide emotional support to relieve anxiety
2. Thorough bowel cleansing
a. Diet modification:
i. Low residue diet 3-5 days preoperative, to reduce the bulk of stool in the colon.
ii. Clear liquid diet 24 hours preoperative.
b. Mechanical cleansing like a laxative, cleansing enema as orders
3. Pharmacologic suppression of colon bacteria: Neomycin Sulfate tablets to reduce bacterial flora
4. Vitamin K supplement because these are lost during repeated enema administration.

Colostomy: a temporary or permanent opening of the colon through the abdominal wall. The stoma is the part of
the colon that is brought above the abdominal wall in a colostomy and becomes the outlet for the discharge of
intestinal contents.

Types of Colostomies

NCM-116
1. Ascending Colostomy
a. Stoma is on the right abdomen
b. Fecal drainage is watery (fluid feces)
2. Transverse Colostomy
a. Stoma located on upper midline abdomen
b. Semi-formed feces (mushy feces)
3. Transverse (Double-Barreled) Colostomy: the colon is resected and both ends are brought through the
abdominal wall creating two stomas, a proximal stoma (end stoma) which drains stool and distal stoma
(mucous fistula) which drains mucus.
4. Transverse Loop Colostomy: a bowel loop is brought to the abdominal wall through an incision and
stabilized temporarily with a glass rod or plastic brace.
a. Has two openings in the transverse colon, but one stoma
b. Indicated in IBD
5. Descending and Sigmoid Colostomy
a. Stoma is on the left abdomen
b. Fecal material is well-formed (solid feces)

Postoperative Care
1. Managing the perineal wound (APR)
a. It may require up to 6 months to completely heal
b. Wound irrigations with normal saline and absorbent dressing until the wound closes.
c. T-binder is used to secure the perineal dressing.
d. Warm sitz bath once the patient is ambulatory to promote healing and to relieve pain in the
perineal area
e. Foam pads or soft pillows to promote comfort when sitting.
f. Side-lying position during sleep.
2. Stoma Monitoring
a. The stoma is red and slightly edematous for 5-7 days, then it becomes pinkish or pinkish-red and
moist.
b. Dark, dusky, or brown-black stoma indicates ischemia and necrosis.
c. The stoma should protrude by ½ to ¾ inch over the abdomen.
d. Flatus and fecal drainage usually begin in 4 to 7 days, as peristalsis returns.
e. Empty the pouch when it is 1/3 to1/2 full of stool.
3. Colostomy Irrigation
a. Position in a side-lying position or sitting on the toilet in the bathroom if bed rest is not necessary.
b. Warm the solution (if it’s too cool, the patient may experience cramping)
c. Hang solution bag 18 to 24 inches above the stoma.

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15
 d.
Lubricate the tip of the stoma cone or catheter.
e.
Insert stoma cone or catheter by using a rotating motion until it fits snugly (about 3 inches). Do
not insert against resistance.
f. Open tubing clamp, allowing the irrigating solution to flow into the bowel slowly. If cramping
occurs, stop the flow until cramps subside.
g. Introduce solution slowly over a period of 5-6 minutes
h. After instillation of fluid (INITIAL-500 ml: STABLE-1000ml), remove cone or catheter, and allow
the colon to empty. Gently massage the abdomen to encourage emptying of the colon (usually
takes up to half an hour).
i. Perform irrigation around the same time each day preferably 1 hour after the meal.
4. Managing odor
a. Small frequent feeding
b. Avoid GAS-forming (Gum, Alcohol, Smoking) foods (broccoli, cabbage, cauliflower, mushroom,
peanuts, beans, root crops, onions, asparagus)
c. Avoid odor forming foods: (protein-rich food)
d. Recommended foods: yogurt, buttermilk, crackers, & cranberry juice
e. Ways to control odor:
i. Promote green leafy vegetable: Ampalaya
ii. Bismuth (subgallate or subcarbonate)
iii. Charcoal
iv. Deodorizer/deodorant tablet
v. Eat yogurt, buttermilk, & cranberry juice

Patient Education
1. Stoma Care

NCM-116
a. Gently encourage the client to look at the stoma.
b. Inform that stoma has no touch or pain sensation. Protect stoma from trauma.
c. Instruct to report immediately any purple or black discoloration of the stoma.
d. Clean the stoma initially with sterile normal saline or antiseptic solution until the stoma is healed.
2. Skin Care
a. Wash the skin around the stoma with warm water and mild soap. Pat the area dry.
b. Assess skin for signs of irritation or infection
c. When pouch seal leaks, change pouch immediately to prevent irritation and infection.
d. Use skin barriers to protect the peristomal skin from liquid stool like karaya preparation.
e. Skin infection caused by Candida Albicans is treated with Mycostatin (nystatin) powder.
3. Support a positive Self-Concept
a. Encourage to verbalize feelings, fear, and concern about the stoma.
b. Encourage to participate in colostomy care.
c. Encourage gradual resume all activities.
d. Avoid tight belts or waistbands over the stoma.
e. Advise to always carry colostomy supplies when traveling.
f. Resolve grief by encouraging the patient to express the feeling of loss and explore usual coping
strategies for handling grief.
4. Prevent Sexual Dysfunction
a. Explore a position that minimized stress and pressure on the pouch.
b. Empty and clean the pouch before sexual activity.
c. Use smaller – sized pouch or pouch cover during sexual activity
d. Use of a binder or special underwear to hold the pouch secure

HEMORRHOIDS
Enlarged (dilated) vein in the lower rectum and anus resulting from congestion in the veins

Types
1. External- occurs below the anal sphincter
2. Internal- occurs above the anal sphincter

Predisposing Factors
1. Chronic constipation, pregnancy, obesity & heavy lifting
2. Prolonged sitting & standing
3. Wearing constrictive clothing
4. Disease conditions like liver cirrhosis & congestive heart failure

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16
Pathophysiology
Increased intra-abdominal pressure causes engorgement or dilation in the vascular tissue lining the anal canal.
↓
Engorged or dilated veins stretched the underlying mucous membrane & skin
↓
Dilated veins protrude in the anal canal
↓
Passage of hard stool can traumatize or pushed the dilated veins outside the anus

Clinical Manifestations
1. Bleeding during or after defecation, bright red blood on the stool because of injury of the mucosa covering
hemorrhoid.
2. Visible protrusion (if external) and a palpable mass.
3. Constipation in an effort to prevent pain or bleeding associated with defecation
4. A sensation of incomplete evacuation
5. Anal/rectal pain
6. Infection or ulceration, mucus discharge

Diagnostic Evaluation
1. History and visualization (ocular inspection) by external examination through anoscopy or
proctosigmoidoscopy.
2. Digital Rectal Examination

Medical Management
1. Bulk laxative and stool softeners to assist with bowel movements

NCM-116
2. Analgesics as needed

Surgical Management
1. Rubber ring ligation: hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to
hemorrhoid (internal hemorrhoids). During anoscopy, the hemorrhoid is grasped with an instrument, and
a device places a rubber band around the base of the hemorrhoid. Hemorrhoid then shrinks and dies and,
in about a week, falls off.
2. Hemorrhoidectomy: excision of internal/external hemorrhoids.

Nursing Management
1. High fiber & liberal fluid intake
2. Cold packs initially followed by a hot sitz bath or warm compress to relieve pain

Preoperative Care
1. Low residue diet to reduce the bulk of stool
2. Stool softener or enema to promote cleansing the bowel.

Postoperative Care
1. Promotion of comfort
a. Analgesic as prescribed
b. Side-lying position
c. Warm sitz bath or warm compresses 12 to 24 hours postoperative to reduce pain and inflammation
2. Promotion of Elimination
a. Stool softener as prescribed to assist with bowel movements soon after surgery
b. Encourage the client to defecate as soon as the urge occurs.
c. Analgesic before initial defecation.
d. Enema as prescribed, using a small-bore rectal tube.
e. Encourage regular exercise, a high-fiber diet, and adequate fluid intake (8 to 10 glasses/day) to
avoid straining and constipation.
3. Patient Teaching
a. Clean rectal area thoroughly after each defecation
b. Avoid constipation
c. Use stool softener until healing is complete.
d. Notify physician postoperatively for rectal bleeding and suppurative drainage.

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17
 Activity
Written Assignment: Develop a chart comparing the etiology, clinical manifestations, and management
of gastritis and peptic ulcer.
Group Assignments: 1. Compare and contrast Crohn’s disease (regional enteritis) and ulcerative colitis.
Include pathophysiology, clinical manifestations, diagnostic evaluation, and management; 2. Divide into three
groups. Discuss strategies aimed at preventing and treating obesity including lifestyle modifications,
pharmacologic therapy, and nonsurgical interventions.
Web Assignment: Using the Internet, locate information about the various types of intestinal
obstructions and their management.

Interactive Link
tinyurl.com/fat3o8ja (Appendicitis)
tinyurl.com/24j2ybap (Peptic Ulcer Disease Part-1)
tinyurl.com/1hz1vixn (Peptic Ulcer Disease Part-2)
tinyurl.com/1lcmn7z7 (Diverticulosis/Diverticulitis)
tinyurl.com/1vn87t73 (Crohn’s Disease versus Ulcerative Colitis)

Summary
Tobacco and alcohol use contribute to several upper GI disorders, including GERD, oral and esophageal
cancers, and peptic ulcer disease. Encourage all people to stop smoking and to reduce alcohol to moderate
amounts, to reduce their risk of developing these disorders.
Gastroesophageal reflux disease (GERD) is common. Prolonged exposure of the lower esophagus to gastric

NCM-116
juices can lead to esophagitis, hemorrhage, and scarring.
Gastric cancer is often diagnosed late in the disease because the symptoms may be vague. Therefore,
encourage people with complaints of dysphagia, a sensation of gastric fullness, or heartburn to seek medical
evaluation. Surgical resection of the cancerous portion of the stomach is the treatment of choice when the tumor
is diagnosed early.
Upper gastrointestinal bleeding can lead to significant blood loss and shock. Peptic ulcer disease accounts
for the majority of UGI hemorrhage, although erosive gastritis and esophageal varices also are common causes.
Helicobacter pylori infection also is a major risk factor for peptic ulcer disease. Effectively treating the
infection can reduce or eliminate the risk of future exacerbations of PUD.
An acute change like abdominal pain in a person with PUD, especially when accompanied by vomiting,
guarding of the abdomen, or a change in bowel sounds, could indicate an obstruction or perforation and release
of gastric contents into the peritoneal cavity.
Appendicitis is an acute inflammation of the vermiform appendix, manifested by abdominal pain that
localizes in the right lower quadrant of the abdomen. On palpation, localized and rebound tenderness is present
at McBurney’s point. It is treated most often with an appendectomy.
Peritonitis (inflammation of the peritoneum from infection or chemical irritant) is a serious complication of
a wide variety of acute abdominal disorders, including perforated ulcer, ruptured appendix, abdominal trauma or
surgery, or necrotic bowel. Complications may be life-threatening; without prompt and effective treatment,
septicemia and septic shock may occur.
Malignant tumors of the lower bowel are the third leading cause of death from cancer. The risk of colon
cancer may be reduced through health-related screenings and a diet high in fruits, vegetables, folic acid, and
calcium. Rectal bleeding is the most common initial manifestation but may not occur until the cancer is well
advanced. Surgical treatment is through surgical resection of the bowel, accompanied by a colostomy for diversion
of fecal contents.
Chronic inflammatory bowel disease (IBD) includes two separates but closely related conditions: ulcerative
colitis and Crohn’s disease. Ulcerative colitis affects the mucosa and submucosa of the colon and rectum. Crohn’s
disease can affect any part of the GI tract, but usually involves the terminal ileum and ascending colon. Diarrhea
is common in both disorders. A colectomy (removal of the large colon) may be performed to treat ulcerative colitis;
an ileostomy (artificial opening from the abdomen to the ileum) may be performed to treat Crohn’s disease.
Diverticula are sac-like projections of mucosa through the muscular layer of the colon. When these sacs
become inflamed, the condition is labeled diverticulitis. A diet high in fiber is recommended for self-care.
Anorectal disorders include hemorrhoids and anorectal lesions (fissure, abscess, and fistula). These
disorders are painful and pose a risk of bleeding and infection.

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18
 CASE STUDY: Cancer of the Rectum
Patient Profile
Peter, a 62-year-old married college teacher, has undergone an abdominal-perineal resection for stage III
cancer of the rectum. He is 1 day postoperative on the general surgical unit.
Subjective Data
• Complains of pain in his abdominal and perineal incisions that are not well controlled even with his
patient-controlled analgesia (PCA) machine
• Jokes about his stoma winking at him when the dressings are removed the first time and a temporary
colostomy bag is applied
• Refers to his stoma as “Jake”
• Tells his wife that “Jake” will be watching her
Objective Data
• Bright-red stoma on left lower quadrant of abdomen; colostomy bag has a small amount of pink mucus
drainage
• Midline abdominal incision; no signs of infection; sutures intact
• Perineal incision partially closed; two Penrose drains with bulky dressings with a large amount of
serosanguineous drainage
• All vital signs normal
• PCA orders of 1 mg morphine sulfate every 10 minutes, with 17 attempts in the past hour

Discussion Questions

NCM-116
Using a separate sheet of paper, answer the following questions:
1. What symptoms may have alerted Peter to seek medical care for his cancer of the rectum?
2. What care is indicated for Peter’s perineal wound?
3. What are the primary goals of care for Peter’s colostomy?
4. What would be the nurse’s evaluation of Peter’s adjustment to his colostomy?
5. What factors may be influencing the pain that Peter is experiencing?
6. Priority Decision: What are the priority teaching needs for Peter before his discharge?
7. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses?

Readings and References

Textbook of Medical-Surgical Nursing-13th Edition. Brunner & Suddarth, 2014
Lippincott Manual of Nursing Practice 11th Edition. Nettina et al., 2019
LeMone, Medical-Surgical Nursing, Critical Thinking for Person-centered Care. 3rd Edition. Pearson
Australia, 2017
Medical-Surgical Nursing, Concepts, and Clinical Applications. 3rd edition. Josie Quiambao-Udan, 2017.
Medical-Surgical Nursing 8th Edition. Joyce Black, 2014
Mosby’s Comprehensive Review of Nursing 20th Edition. Nugent et al., 2014
Assessment & Management of Clinical Problems 9th Edition. Lewis et al., 2014
Anatomy and Physiology. Tortora. 2008.
Pathophysiology Review. Marlene Hurst, 2008

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