BACHELOR OF SCIENCE IN NURSING

NCMB 316 - CARE OF CLIENTS WITH PROBLEMS IN

NUTRITIONAL AND GASTROINTESTINAL METABOLISM
AND ENDOCRINE, PERCEPTION AND COORDINATION
(ACUTE AND CHRONIC)
COURSE MODULE COURSE UNIT WEEK
1 2 2

DISTURBANCES IN ABSORPTION AND ELIMINATION

✓ Read course and unit objectives

✓ Read study guide prior to class attendance
✓ Read required learning resources; refer to unit
terminologies for jargons
✓ Proactively participate in classroom discussions
✓ Participate in weekly discussion board (Canvas)
✓ Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Identify the health care learning needs of patients with constipation or diarrhea.
2. Compare the conditions of malabsorption with regard to their pathophysiology, clinical
manifestations, and management.
3. Use the nursing process as a framework for care of patients with diverticular disease.
4. Compare Crohn’s disease (regional enteritis) and ulcerative colitis with regard to their
pathophysiology; clinical manifestations; diagnostic evaluation; and medical, surgical, and
nursing management.
5. Use the nursing process as a framework for care of the patient with inflammatory bowel
disease.
 6. Describe the responsibilities of the nurse in meeting the needs of the patient with an intestinal
diversion.
7. Describe the various types of intestinal obstructions and their management.
8. Use the nursing process as a framework for care of the patient with cancer of the colon or
rectum.
9. Describe nursing management of the patient with an anorectal condition.
Psychomotor:
1. Utilize and demonstrate safety principles and concepts in the performance of IV and blood
therapies.
2. Practice beginning skills in promoting healthy physiologic and psychosocial responses.
3. Operate appropriate technology in the performance of IVT and BT.
4. Participate in research by analyzing possible problems in the practice of IVT and BT.
5. Participate actively during class discussions
6. Confidently express opinion and thoughts in front of the class.
Affective:
1. Exemplify caring attitude(s) in the performance of procedures in a simulated scenario.
2. Demonstrate caring as the core of nursing, love of God, love of country, love of people.
3. Integrate being an A.C.H.I.E.V.E.R. in the performance of IVT and BT procedures.

Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's textbook of medical-surgical
nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

I. INTESTINAL OBSTRUCTION

Intestinal obstruction exists when blockage prevents

the normal flow of intestinal contents through the
intestinal tract. Two types of processes can impede
this flow:
• Mechanical obstruction: An intraluminal obstruction
or a mural obstruction from pressure on the intestinal
wall occurs. Examples are intussusception, polypoid
tumors and neoplasms, stenosis, strictures,
adhesions, hernias, and abscesses.
• Functional obstruction: The intestinal musculature
cannot propel the contents along the bowel.
Examples are amyloidosis, muscular dystrophy,
endocrine disorders such as diabetes mellitus, or
neurologic disorders such as Parkinson’s disease.
The blockage also can be temporary and the result
of the manipulation of the bowel during surgery. The
obstruction can be partial or complete. Its severity
depends on the region of bowel affected, the degree
to which the lumen is occluded, and especially the
degree to which the vascular supply to the bowel wall is disturbed.

Most bowel obstructions occur in the small intestine. Adhesions are the most common cause of small
bowel obstruction, followed by hernias and neoplasms. Other causes include intussusception, volvulus
(ie, twisting of the bowel), and paralytic ileus. Most obstructions in the large bowel occur in the sigmoid
colon. The most common causes are carcinoma, diverticulitis, inflammatory bowel disorders, and
benign tumors. Table 38-5 and Figure 38-7 list mechanical causes of obstruction and describe how
they occur.

Small Bowel Obstruction

Pathophysiology
Intestinal contents, fluid, and gas accumulate above the
intestinal obstruction. The abdominal distention and
retention of fluid reduce the absorption of fluids and
stimulate more gastric secretion. With increasing
distention, pressure within the intestinal lumen increases,
causing a decrease in venous and arteriolar capillary
pressure. This causes edema, congestion, necrosis, and
eventual rupture or perforation of the intestinal wall, with
resultant peritonitis.

Reflux vomiting may be caused by abdominal distention.

Vomiting results in loss of hydrogen ions and potassium
from the stomach, leading to reduction of chlorides and potassium in the blood and to metabolic
alkalosis. Dehydration and acidosis develop from loss of water and sodium. With acute fluid losses,
hypovolemic shock may occur.

Clinical Manifestations
The initial symptom is usually crampy pain that is wavelike and colicky. The patient may pass blood
and mucus but no fecal matter and no flatus. Vomiting occurs. If the obstruction is complete, the
peristaltic waves initially become extremely vigorous and eventually assume a reverse direction, with
the intestinal contents propelled toward the mouth instead of toward the rectum. If the obstruction is in
the ileum, fecal vomiting takes place. First, the patient vomits the stomach contents, then the bile
stained contents of the duodenum and the jejunum, and finally, with each paroxysm of pain, the darker,
fecal-like contents of the ileum. The signs of dehydration become evident: intense thirst, drowsiness,
generalized malaise, aching, and a parched tongue and mucous membranes.
The abdomen becomes distended. The lower the obstruction is in the GI tract, the more marked the
abdominal distention. If the obstruction continues uncorrected, hypovolemic shock occurs from
dehydration and loss of plasma volume.

Assessment and Diagnostic Findings

Diagnosis is based on the symptoms described previously and on imaging studies. Abdominal x-ray
and CT findings include abnormal quantities of gas, fluid, or both in the intestines. Laboratory studies
(ie, electrolyte studies and a complete blood cell count) reveal a picture of dehydration, loss of plasma
volume, and possible infection.

Medical Management
Decompression of the bowel through a nasogastric tube is successful in most cases. When the bowel
is completely obstructed, the possibility of strangulation and tissue necrosis (ie, tissue death) warrants
surgical intervention. Before surgery, IV fluids are necessary to replace the depleted water, sodium,
chloride, and potassium.

The surgical treatment of intestinal obstruction depends on the cause of the obstruction. For the most
common causes of obstruction, such as hernia and adhesions, the surgical procedure involves
repairing the hernia or dividing the adhesion to which the intestine is attached. In some instances, the
portion of affected bowel may be removed and an anastomosis performed. The complexity of the
surgical procedure depends on the duration of the intestinal obstruction and the condition of the
intestine.

Nursing Management
Nursing management of the nonsurgical patient with a small bowel obstruction includes maintaining the
function of the nasogastric tube, assessing and measuring the nasogastric output, assessing for fluid
and electrolyte imbalance, monitoring nutritional status, and assessing improvement (eg, return of
normal bowel sounds, decreased abdominal distention, subjective improvement in abdominal pain and
tenderness, passage of flatus or stool). The nurse reports discrepancies in intake and output,
worsening of pain or abdominal distention, and increased nasogastric output. If the patient’s condition
does not improve, the nurse prepares him or her for surgery.
Nursing care of the patient after surgical repair of a small
bowel obstruction is similar to that for other abdominal
surgeries.

Large Bowel Obstruction

Pathophysiology
As in small bowel obstruction, large bowel obstruction results
in an accumulation of intestinal contents, fluid, and gas
proximal to the obstruction. It can lead to severe distention
and perforation unless some gas and fluid can flow back
through the ileal valve. Large bowel obstruction, even if
complete, may be undramatic if the blood supply to the colon
is not disturbed. However, if the blood supply is cut off,
intestinal strangulation and necrosis occur; this condition is
life-threatening. In the large intestine, dehydration occurs more
slowly than in the small intestine because the colon can
absorb its fluid contents and can distend to a size considerably
beyond its normal full capacity.
 Adenocarcinoid tumors account for the majority of large bowel obstructions. Most tumors occur beyond
the splenic flexure, making them accessible with a flexible sigmoidoscope.

Clinical Manifestations
Large bowel obstruction differs clinically from small bowel obstruction in that the symptoms develop
and progress relatively slowly. In patients with obstruction in the sigmoid colon or the rectum,
constipation may be the only symptom for months. The shape of the stool is altered as it passes the
obstruction that is gradually increasing in size. Blood loss in the stool may result in iron deficiency
anemia. The patient may experience weakness, weight loss, and anorexia. Eventually, the abdomen
becomes markedly distended, loops of large bowel become visibly outlined through the abdominal wall,
and the patient has crampy lower abdominal pain. Finally, fecal vomiting develops. Symptoms of
shock may occur.

Assessment and Diagnostic Findings

Diagnosis is based on symptoms and on imaging studies. Abdominal x-ray and abdominal CT or MRI
findings reveal a distended colon and pinpoint the site of the obstruction. Barium studies are
contraindicated.

Medical Management
Restoration of intravascular volume, correction of electrolyte abnormalities, and nasogastric aspiration
and decompression are instituted immediately. A colonoscopy may be performed to untwist and
decompress the bowel. A cecostomy, in which a surgical opening is made into the cecum, may be
performed in patients who are poor surgical risks and urgently need relief from the obstruction. The
procedure provides an outlet for releasing gas and a small amount of drainage. A rectal tube may be
used to decompress an area that is lower in the bowel. However, the usual treatment is surgical
resection to remove the obstructing lesion. A temporary or permanent colostomy may be necessary. An
ileoanal anastomosis may be performed if removal of the entire large bowel is necessary.

Nursing Management
The nurse’s role is to monitor the patient for symptoms that indicate that the intestinal obstruction is
worsening and to provide emotional support and comfort. The nurse administers IV fluids and
electrolytes as prescribed. If the patient’s condition does not respond to nonsurgical treatment, the
nurse prepares the patient for surgery. This preparation includes preoperative teaching as the patient’s
condition indicates. After surgery, general abdominal
wound care and routine postoperative nursing care
are provided.

II. Regional Enteritis (Crohn’s Disease)

Regional enteritis is a subacute and chronic

inflammation of the gastrointestinal (GI) tract wall
that extends through all layers. Crohn’s disease is
usually first diagnosed in adolescents or young
adults but can appear at any time of life. Although
the most common areas in which it is found are the
distal ileum and colon, it can occur anywhere along
the GI tract. Fistulas, fissures, and abscesses form
as the inflammation extends into the peritoneum. In
advanced cases, the intestinal mucosa has a
 cobblestone like appearance. As the disease advances, the bowel wall thickens and becomes fibrotic
and the intestinal lumen narrows. The clinical course and symptoms vary. In some patients, periods of
remission and exacerbation occur, but in others, the disease follows a fulminating course.

Clinical Manifestations
• Onset of symptoms is usually insidious, with prominent right lower quadrant abdominal pain and
diarrhea unrelieved by defecation.
• Abdominal tenderness and spasm.
• Crampy pains occur after meals; the patient tends to limit intake, causing weight loss, malnutrition,
and secondary anemia.
• Chronic diarrhea may occur, resulting in a patient who is uncomfortable and is thin and emaciated
from inadequate food intake and constant fluid loss. The inflamed intestine may perforate and form
intra-abdominal and anal abscesses.
• Fever and leukocytosis occur.
• Abscesses, fistulas, and fissures are common.
• Symptoms extend beyond the GI tract to include joint disorders (eg, arthritis), skin lesions (eg,
erythema nodosum), ocular disorders (eg, conjunctivitis), and oral ulcers.

Assessment and Diagnostic Methods

• Barium study of the upper GI tract is the most conclusive diagnostic aid; shows the classic “string
sign” of the terminal ileum (constriction of a segment of intestine) as well as cobblestone
appearance, fistulas, and fissures.
• Endoscopy, colonoscopy, and intestinal biopsies may be used to confirm the diagnosis.
• Proctosigmoidoscopic examination, computed tomography (CT) scan.
• Stool examination for occult blood and steatorrhea.
• Complete blood cell count (decreased Hgb and Hct), sedimentation rate (elevated), albumin, and
protein levels (usually decreased due to malnutrition).

III. Appendicitis

The appendix is a small, finger-like appendage attached

to the cecum just below the ileocecal valve. Because it
empties into the colon inefficiently and its lumen is small, it
is prone to becoming obstructed and is vulnerable to
infection (appendicitis). The obstructed appendix becomes
inflamed and edematous and eventually fills with pus. It is
the most common cause of acute inflammation in the right
lower quadrant of the abdominal cavity and the most
common cause of emergency abdominal surgery.
Although it can occur at any age, it more commonly
occurs between the ages of 10 and 30 years.

Clinical Manifestations
• Lower right quadrant pain usually accompanied by
lowgrade fever, nausea, and sometimes vomiting; loss
of appetite is common; constipation can occur.
• At McBurney’s point (located halfway between the
umbilicus and the anterior spine of the ilium), local
tenderness with pressure and some rigidity of the
lower portion of the right rectus muscle.
 • Rebound tenderness may be present; location of
appendix dictates amount of tenderness, muscle
spasm, and occurrence of constipation or diarrhea.
• Rovsing’s sign (elicited by palpating left lower
quadrant, which paradoxically causes pain in right
lower quadrant).
• If appendix ruptures, pain becomes more diffuse;
abdominal distention develops from paralytic ileus, and
condition worsens.

Assessment and Diagnostic Findings

• Diagnosis is based on a complete physical
examination and laboratory and imaging tests.
• Elevated WBC count with an elevation of the
neutrophils; abdominal radiographs, ultrasound studies, and CT scans may reveal right lower
quadrant density or localized distention of the bowel.

Medical Management
• Surgery (conventional or laparoscopic) is indicated if appendicitis is diagnosed and should be
performed as soon as possible to decrease risk of perforation.
• Administer antibiotics and IV fluids until surgery is performed.
• Analgesic agents can be given after diagnosis is made.

Complications of Appendectomy
• The major complication is perforation of the appendix, which can lead to peritonitis, abscess
formation (collection of purulent material), or portal pylephlebitis.
• Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever of 37.7_C
(100_F) or greater, a toxic appearance, and continued abdominal pain or tenderness.

Nursing Management
• Nursing goals include relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating
infection due to the potential or actual disruption of the GI tract, maintaining skin integrity, and
attaining optimal nutrition.
• Preoperatively, prepare patient for surgery, start IV line, administer antibiotic, and insert nasogastric
tube (if evidence of paralytic ileus). Do not administer an enema or laxative (could cause
perforation).
• Postoperatively, place patient in high Fowler’s position, give narcotic analgesic as ordered,
administer oral fluids when tolerated, give food as
desired on day of surgery (if tolerated). If dehydrated
before surgery, administer IV fluids.
• If a drain is left in place at the area of the incision,
monitor carefully for signs of intestinal obstruction,
secondary hemorrhage, or secondary abscesses (eg,
fever, tachycardia, and increased leukocyte count).

IV. Peritonitis

Peritonitis, inflammation of the peritoneum, is usually the

result of bacterial infection, with the organisms coming from
disease of the GI tract, or, in women, the internal
reproductive organs. It can also result from external
sources, such as injury or trauma or an inflammation from an extraperitoneal organ, such as the kidney.

Pathophysiology
Peritonitis is caused by leakage of contents from abdominal organs into the abdominal cavity, usually
as a result of inflammation, infection, ischemia, trauma, or tumor perforation. The most common
bacteria implicated are Escherichia coli, and Klebsiella, Proteus, and Pseudomonas species. Other
common causes are appendicitis, perforated ulcer, diverticulitis, and bowel perforation. Peritonitis may
also be associated with abdominal surgical procedures and peritoneal dialysis. Sepsis is the major
cause of death from peritonitis (shock, from sepsis or hypovolemia). Intestinal obstruction from bowel
adhesions may develop.

Clinical Manifestations
Clinical features depend on the location and extent of inflammation.
• Diffuse pain becomes constant, localized, and more intense near site of the process.
• Pain is aggravated by movement.
• Affected area of the abdomen becomes extremely tender and distended, and muscles become
rigid.
• Rebound tenderness and paralytic ileus may be present.
• Anorexia, nausea, and vomiting occur and peristalsis is diminished.
• Temperature and pulse increase; hypotension may develop.

Assessment and Diagnostic Methods

• Leukocytes (elevated) and serum electrolytes (altered potassium, sodium and chloride)
• Abdominal x-rays, ultrasound, CT scan, MRI, and peritoneal aspiration with culture and sensitivity
studies

Medical Management
• Fluid, colloid, and electrolyte replacement with an isotonic solution is the major focus of medical
management.
• Analgesics are administered for pain; antiemetics are administered for nausea and vomiting.
• Intestinal intubation and suction are used to relieve abdominal distention.
• Oxygen therapy by nasal cannula or mask is instituted to improve ventilatory function.
• Occasionally, airway intubation and ventilatory assistance are required.
•Massive antibiotic therapy may be instituted (sepsis is the major cause of death).
• Surgical objectives include removal of infected material; surgery is directed toward excision
(appendix), resection (intestine), repair (perforation), or drainage (abscess).

Nursing Management
• Monitor the patient’s blood pressure by arterial line if shock is present.
• Monitor central venous or pulmonary artery pressures and urine output frequently.
• Provide ongoing assessment of pain, GI function, and fluid and electrolyte balance.
• Assess nature of pain, location in the abdomen, and shifts of pain and location.
• Administer analgesic medication and position for comfort (eg, on side with knees flexed to decrease
tension on abdominal organs).
• Record intake and output and CVP and/or pulmonary artery pressures.
• Administer and monitor IV fluids closely; nasogastric intubation may be necessary.
• Observe for decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic
sounds, and passage of flatus and bowel movements, which indicate peritonitis is subsiding.
• Increase food and oral fluids gradually, and decrease parenteral fluid intake when peritonitis
subsides.
 • Observe and record character of drainage from postoperative wound drains if inserted; take care to
avoid dislodging drains.
• Postoperatively, prepare patient and family for discharge; teach care of incision and drains if still in
place at discharge.
• Refer for home care if necessary.

V. Diverticular Disease

A diverticulum is a saclike herniation of the lining of the

bowel that extends through a defect in the muscle
layer. Diverticula may occur anywhere in the small
intestine or colon but most commonly occur in the
sigmoid colon. Diverticulosis exists when multiple
diverticula are present without inflammation or
symptoms. It is most common in people older than 80
years. A low intake of dietary fiber is considered a
major predisposing factor. Diverticulitis results when
food and bacteria retained in the diverticulum produce
infection and inflammation that can impede draining
and lead to perforation or abscess. It may occur in
acute attacks or persist as a chronic, smoldering
infection. A congenital predisposition is likely when the
disorder is present in those younger than 40 years.
Complications of diverticulitis include abscess, fistula
(abnormal tract) formation, obstruction, perforation,
peritonitis, and hemorrhage.

Clinical Manifestations
Diverticulosis
• Frequently, no problematic symptoms are noted; chronic constipation often precedes development.
• Bowel irregularity with intervals of diarrhea, nausea and anorexia, and bloating or abdominal
distention.
• Cramps, narrow stools, and increased constipation or at times intestinal obstruction.
• •Weakness, fatigue, and anorexia.
Diverticulitis
• Acute onset of mild to severe pain in the left lower quadrant
• Nausea, vomiting, fever, chills, and leukocytosis
• If untreated, peritonitis and septicemia

Assessment and Diagnostic Findings

• Colonoscopy and possibly barium enema studies
• Computed tomography (CT) scan with contrast agent
• Abdominal x-ray
• Laboratory tests: complete blood cell count, revealing an elevated white blood cell count, and
elevated erythrocyte sedimentation rate (ESR)

Medical Management
Dietary and Pharmacologic Management
• Diverticulitis can usually be treated on an outpatient basis with diet and medication; symptoms
treated with rest, analgesics, and antispasmodics.
 • The patient is instructed to ingest clear liquids until inflammation subsides, then a high-fiber, low-fat
diet. Antibiotics are prescribed for 7 to 10 days and a bulk-forming laxative is also prescribed.
• Patients with significant symptoms and often those who are elderly, immunocompromised, or taking
corticosteroids are hospitalized. The bowel is rested by withholding oral intake, administering IV
fluids, and instituting nasogastric suctioning.
• Broad-spectrum
antibiotics and analgesics
are prescribed and an
opioid is prescribed for
pain relief. Oral intake is
increased as symptoms
subside. A low-fiber diet
may be necessary until
signs of infection
decrease.
• Antispasmodics such as
propantheline bromide
and oxyphencyclimine
(Daricon) may be
prescribed.
• Normal stools can be
achieved by administering
bulk preparations
(psyllium), stool softeners,
warm oil enemas, and
evacuant suppositories.

VI. Hemorrhoids

Hemorrhoids are vascular masses that protrude into the lumen of the lower rectum or perianal area.

• They result when increased intra-abdominal pressure causes engorgement in the vascular tissue
lining the anal canal.
• Loosening of vessels from surrounding connective tissue occurs with protrusion or prolapse into the
anal canal.
• There are two main types of hemorrhoids: external hemorrhoids appear outside the external
sphincter, and internal hemorrhoids appear above the internal sphincter.
• When blood within the hemorrhoids becomes clotted because of obstruction, the hemorrhoids are
referred to as being thrombosed.
• Predisposing factors include pregnancy, prolonged sitting or standing, straining stool, chronic
constipation or diarrhea, anal infection, rectal surgery or episiotomy, genetic predisposition,
alcoholism, portal hypertension (cirrhosis), coughing, sneezing, or vomiting, loss of muscle tone
attributable to old age, and anal intercourse.
• Complications include hemorrhage, anemia, incontinence of stool, and strangulation.
• Hemorrhoids are the most common of a variety of anorectal disorders.

Causes/Risk Factors
Modifiable
▪ Some factors that are associated with hemorrhoids are occupations that require prolonged
sitting or standing; heart failure; anorectal infections; anal intercourse; alcoholism; pregnancy;
colorectal cancer; and hepatic disease such as cirrhosis, amoebic abscesses, or hepatitis.
▪ Straining because of constipation, diarrhea, coughing, sneezing, or vomiting and loss of muscle
tone because of aging, rectal surgery, or episiotomy can also cause hemorrhoids.

Assessment
1. Pain (more so with external hemorrhoids), sensation of incomplete fecal evacuation,
constipation, and anal itching. Sudden rectal pain may occur if external hemorrhoids are
thrombosed.
2. Bleeding may occur during defecation; bright red blood on stool caused by injury of
mucosa covering hemorrhoid.
3. Visible and palpable masses at anal area.

Diagnostic Evaluation
1. External examination with anoscope or proctoscope shows single or multiple hemorrhoids.
2. Barium edema or colonoscopy rules out more serious colonic lesions causing rectal bleeding
such as polyps.

Primary Nursing Diagnosis

▪ Pain (acute or chronic) related to rectal
swelling and prolapse

Therapeutic Intervention /
Medical Management
1. High-fiber diet to keep stools soft.
2. Warm sitz baths to ease pain and combat
swelling.
3. Reduction of prolapsed external
hemorrhoid manually.

Surgical Interventions:
1. Injection of sclerosing solutions to produce scar tissue and decrease prolapse is an office
procedure.
2. Cryodestruction (freezing) of hemorrhoids is an office procedure.
3. Surgery may be indicated in presence of prolonged bleeding, disabling pain, intolerable itching,
and general unrelieved discomfort.

Pharmacologic Intervention
1. Stool softeners to keep stools soft and relieve symptoms.
2. Topical creams, suppositories or other preparation such as Anusol, Preparation H, and witch-
hazel compresses to reduce itching and provide comfort.
3. Oral analgesics may be needed.

Nursing Intervention
1. After thrombosis or surgery, assist with frequent repositioning using pillow support for comfort.
2. Provide analgesics, warm sitz baths, or warm compresses to reduce pain and inflammation.
3. Apply witch-hazel dressing to perianal area or anal creams or suppositories, if ordered, to relieve
discomfort.
4. Observe anal area postoperatively for drainage and bleeding.
5. Administer stool softener or laxative to assist with bowel movements soon after surgery, to reduce
risk of stricture.
6. Teach anal hygiene and measures to control moisture to prevent itching.
7. Encourage the patient to exercise regularly, follow a high fiber diet, and have an adequate fluid
intake (8 to 10 glasses per day) to avoid straining and constipation, which predisposes to
hemorrhoid formation.
8. Discourage regular use of laxatives; firm, soft stools dilate the anal canal and decrease stricture
formation after surgery.
9. Tell patient to expect a foul-smelling discharge for 7 to 10 days after cryodestruction.
10. Determine the patient’s normal bowel habits and identify predisposing factors to educate patient
about preventing recurrence of symptoms.

Documentation Guidelines

1. Physical findings:Rectal examination,urinary retention,bleeding,and mucous drainage

2. Wound healing:Drainage,color,swelling
3. Pain management:Pain (location,duration,frequency),response to interventions
4. Postoperative bowel movements:Tolerance for first bowel movement

Discharge and Home Healthcare Guidelines

Teach the patient the importance of a high-fiber diet, increased fluid intake, mild exercise, and regular
bowel movements. Be sure the patient schedules a follow-up visit to the physician. Teach the patient
which analgesic applications for local pain may be used. If the patient has had surgery, teach her or
him to recognize signs of urinary retention, such as bladder distension and hemorrhage,and to contact
the physician at their appearance.

1. Ascites: Abnormal accumulation of fluid in peritoneal cavity caused by cirrhosis, tumors, and
infection
2. Borborygmus: Rumbling, gurgling sound made by movement of gas in intestine
3. Cathartic: Strong laxative
4. Colonic polyposis: Polyps, small growths protruding from mucous membrane of colon
5. Constipation: Difficult or delayed defecation caused by low peristalsis movement, over-
absorption of water as contents sit too long in the intestine, or by dehydration
6. Diarrhea: Frequent discharge of liquid stool (feces)
7. Diverticula: Abnormal side pockets in hollow structure, such as intestine, sigmoid colon, and
duodenum
8. Flatus: Gas expelled through the anus
9. Hemorrhoids: Swollen or twisted veins either outside or just inside the anus
10. Hernia: A protrusion of an organ or part through the wall of the cavity that contains it
11. Ileus: Intestinal obstruction that can be caused by failure of peristalsis following surgery, hernia,
tumor, adhesions, and often by peritonitis
12. Inguinal hernia: A small loop of bowel protruding through a weak place in the inguinal ring, an
opening in the lower abdominal wall, which allows blood vessels to pass into the scrotum
13. Intussusception: Telescoping of the intestine; common in children
14. Laxative: Medication encouraging movement of feces
15. Melena: Black stool; feces containing blood
16. Polyposis: Condition of polyps in the intestinal wall
17. Pruritus ani: Intense itching of the anal area
18. Steatorrhea: Excessive fat in feces
19. Volvulus: Twisting of intestine upon itself
Ignatavicius, D.D., Workman, M.L., & Rebar, C.R. (2018). Medical-Surgical Nursing: Concepts for
Interprofessional Collaborative Care (9th ed.). St. Louis: Elsevier.
LeMone, P., Burke, K.M., Bauldoff, G., & Gubrud, P. (2015). Medical-Surgical Nursing: Critical
Reasoning in Patient Care (6th ed.). Upper Saddle River, NJ: Pearson/Prentice Hall.
Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017). Medical Surgical
Nursing: Assessment and Management of Clinical Problems (10th ed.). St. Louis: Elsevier.
Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th ed.).
St. Louis: Elsevier.
Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2017). Fundamentals of Nursing (9th ed.). St.
Louis: Elsevier/Mosby.
Wilkinson, J.M., Treas, L.S., Barnett, K.L., & Smith, M.H. (2016). Fundamentals of Nursing: Volume 1-
Theory, Concepts, and Applications; Volume 2- Thinking, Doing, and Caring. (3rd ed.).
Philadelphia: F.A. Davis Co.

A. CASE STUDY: HEMORRHOIDS

A 92-year-old woman in a long-term care facility is a patient assigned to your care. With visible
discomfort, she tells you that she has noticed blood in the toilet bowl with her last several bowel
movements and she has had blood on her underwear.

1. What other questions should you ask this woman to clarify potential causes of this problem?
2. Explain how the patient’s age might affect your focused assessment.

B. CASE STUDY: APPENDICITIS

Rory, an 18 year old girl, is admitted to the hospital with possible diagnosis of appendicitis. She
became symptomatic approximately 24 hours prior to her hospital admission.

1. Since Rory has been symptomatic for 24 hours, what symptoms does the nurse expect to find
when obtaining subjective and objective data that correlates with diagnosis of appendicitis?
2. Before the nurse sends Rory to have any diagnostic x-rays, what procedure should be performed?
3. Two hours after admission, the nurse observes Rory lying motionless and supine in bed and
tells the nurse that she feels worse. What does the nurse suspect may have occurred during this
time frame?
Books
American Cancer Society (ACS). (2008). Cancer facts and figures 2008. Atlanta, GA: Author. Andreoli,
T., Carpenter, D. J., Griggs, R. C., et al. (2007). Cecil essentials of medicine (7th ed.). Philadelphia:
W. B. Saunders.
Chan, P. & Johnson, M. T. (2006). Treatment guidelines for medicine and primary care, 2006. Laguna
Hills, CA: Current Clinical Strategies Publishing.
Doughty, D. (2006). Urinary and fecal incontinence: Current management concepts (3rd ed). St. Louis,
MO: Mosby.
Green, G., Morris, J. & Lin, G. (2005). Washington manual of medical therapeutics (31st ed.).
Philadelphia: Lippincott Williams & Wilkins.
Huether, S. E. & McCance, K. L. (2008). Understanding pathophysiology. St. Louis, MO: Mosby.
McPhee, S. J., Papadakis, M. & Tierney, L. (2007). Current medical diagnosis and treatment, 2007
(46th ed.). New York: McGraw-Hill Medical.
Winshall, J. & Lederman, R. (2006). Tarascon internal medicine and critical care pocketbook (4th ed.).
Loma Linda, CA: Tarascon Publishing.

Journals and Electronic Documents

Beitz, J. (2004). Diverticulosis and diverticulitis: Spectrum of a modern malady. Journal of Wound,
Ostomy and Continence Nursing, 31(2), 75–84.
Centers for Disease Control and Prevention. (2007). Updated recommended treatment regimens for
gonococcal infections and associated conditions—
United States. Available at: www.cdc.gov/std/treatment National Institutes of Health: National Institute
of Diabetes and Digestive and Kidney Diseases. (2007). National digestive diseases information
clearinghouse. Available at: http://digestive.niddk.nih.gov
Peralta, R. & Genuit, T. (2006). Peritonitis and abdominal sepsis. eMedicine,
www.emedicine.com/med/topic2737.htm

Online Resources
www.wocn.org
https://www.radiologyinfo.org/en/info.cfm?pg=lowergi
https://www.nursingtimes.net/clinical-archive
https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Lab-and-Diagnostic
Tests/425143/all/B.
https://nurseslabs.com/digestive-system/
http://www.nlm.nih.gov/medlineplus
https://nurseslabs.com
https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/hemorrhoids/