Gastrointestinal System

Disorders of the Lower G strointestin l Tr ct

Intestin l nd Rect l disorders

P rt I

Adult Nursing II
Ali T her Moh mmed meen

Mond y, November 2020

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 Learning outcomes
On completion of this lecture, the students will be ble to:
• Describe the pathophysiology, clinical manifestations, and

management of patients with lower GI disorder.

• Compare Crohn’s disease and ulcerative colitis with regard to their

pathophysiology; clinical manifestations; diagnostic evaluation; and

medical, surgical, and nursing management.

• Use the nursing process as a framework for care of the patient with
inflammatory bowel disease.

• Describe the features and management of appendicitis and peritonitis.

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 Introduction

• The lower GI tract includes the small and large intestines from the
duodenum to anus.

• The material that moves down the lower GI tract consists of food
residues, microorganisms, digestive secretions, and mucus (feces).

Disorders of the lower GI tract usually affect movement of feces

toward the anus.

• The type and amount of food a person consumes greatly affect

stool consistency.

 Altered Bowel Elimination

• In differentiating normal from abnormal, the consistency of

stools and the comfort with which a person passes them are

more reliable indicators than is the frequency of bowel

elimination.

• Nurses can have an impact on these GI disorders by identifying

behavior and educating the public and helping those affected to

improve their condition and prevent complications.

 Constipation
De ine

• Constipation is de ined as fewer than three bowel movements

weekly or bowel movements that are hard, dry, small, or dif icult

to pass.

• People more likely to become constipated are women,

particularly pregnant women, patients who recently had

surgery, older adults, and those of lower socioeconomic status.

• Notably, constipation is a symptom and not a disease.

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 Constipation
P thophysiology nd Etiology
• The pathophysiology of constipation is poorly understood
• But it is thought to include interference with one of three major functions
of the colon:

1. Mucosal transport (i.e., mucosal secretions facilitate the movement

of colon contents)

2. Myoelectric activity (i.e., mixing of the rectal mass and propulsive

actions)

3. The processes of defecation.

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 Constipation
P thophysiology nd Etiology

• There are three classes of constipation, based upon their

underlying pathophysiologic mechanisms:

A. Functional constipation

B. Slow-transit constipation

C. Defecatory disorders
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 Constipation
P thophysiology nd Etiology
A. Functional constipation: which

involves normal transit mechanisms

of mucosal transport. This type of

constipation is most common and

can be successfully treated by

increasing intake of iber and fluids.

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 Constipation
P thophysiology nd Etiology
B. Slow-transit constipation: which is caused by inherent

disorders of the motor function of the colon (e.g.,

Hirschsprung disease), and is characterized by infrequent

bowel movements.
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 Constipation
P thophysiology nd Etiology
C. Defecatory disorders, which are caused by dysfunctional

motor coordination between the pelvic floor and anal

sphincter..
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 Constipation
Clinic l M nifest tions
• Bowel elimination is infrequent or irregular. Clients describe feeling
bloated. The abdomen may be tympanic or distended, and bowel

sounds may be hypoactive. The client experiences rectal fullness,

pressure, and pain when he or she attempts to eliminate stool. What he

or she passes usually is hard and dry. Rectal bleeding may result as the

tissue stretches and tears while the person tries to pass the hard, dry

stool. When a practitioner inserts a gloved and lubricated inger in the

rectum, the stool may feel like small rocks, a condition referred to as

scybala.
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 Constipation
Di gnostic Findings

• The diagnosis of constipation is based on the patient’s history,

physical examination, possibly the results of a barium enema or

sigmoidoscopy, and stool testing for occult blood.

• Secondary causes of constipation should be excluded. In

patients with severe, intractable constipation, further

diagnostic testing is needed.

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 Constipation
Medic l M n gement
• Treatment targets the underlying cause of constipation and prevention
of recurrence. It includes education, exercise, bowel habit training,

increased iber and fluid intake, and judicious use of laxatives.

Management may also include discontinuing laxative use or replacing

medications that could cause or exacerbate constipation with other

non-constipating medications. Routine exercise to strengthen

abdominal muscles is encouraged. Enemas and rectal suppositories are

generally not recommended for treating constipation unless other

medications have failed; then, glycerin suppositories may be tried.

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 Constipation
Nursing M n gement
• The nurse elicits information about the onset and duration of constipation, current and
past elimination patterns, the patient’s expectation of normal bowel elimination, and

lifestyle information (e.g., exercise and activity level, occupation, food and fluid intake,

and stress level) during the health history interview. Past medical and surgical history,

current medications, and laxative and enema use are important, as is information about

the sensation of rectal pressure or fullness, abdominal pain, excessive straining at

defecation, and flatulence. Goals for the patient include restoring or maintaining a

regular pattern of elimination by responding to the urge to defecate, ensuring adequate

intake of fluids and high- iber foods, learning about methods to avoid constipation,

relieving anxiety about bowel elimination patterns, and avoiding complications.

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 Diarrhea
De ine

• Diarrhea is an increased frequency of bowel movements (more

than 3 per day) with altered consistency (i.e., increased liquidity)

of stool.

• Diarrhea can be classi ied as acute, persistent, or chronic. Acute

diarrhea is self-limiting, lasting 1 or 2 days; persistent diarrhea

typically lasts between 2 and 4 weeks; and chronic diarrhea

persists for more than 4 weeks and may return sporadically.

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 Diarrhea
P thophysiology
• Acute and persistent diarrheas are classi ied as either noninflammatory
(large-volume) or inflammatory (small-volume). Enteric pathogens that

are noninvasive (e.g., S. aureus, Giardia) do not cause inflammation but

secrete toxins that disrupt colonic fluid transport. They cause

noninflammatory diarrhea, which is characterized by a large volume of

loose, watery stools. Other pathogens that invade the intestinal

mucosa and cause inflammatory changes typically result in smaller

volumes of stool that is bloody (e.g., dysentery). Organisms implicated

may include Shigella, Salmonella, and Yersinia species

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 Diarrhea
P thophysiology
• Types of chronic diarrhea include secretory, osmotic, malabsorptive, infectious, and exudative.
Secretory diarrhea is usually high-volume diarrhea. Often associated with bacterial toxins and

chemotherapeutic agents used to treat neoplasms, it is caused by increased production and

secretion of water and electrolytes by the intestinal mucosa into the intestinal lumen. Osmotic

diarrhea occurs when water is pulled into the intestines by the osmotic pressure of unabsorbed

particles, slowing the reabsorption of water. It can be caused by lactase de iciency, pancreatic

dysfunction, or intestinal hemorrhage. Malabsorptive diarrhea combines mechanical and

biochemical actions, inhibiting effective absorption of nutrients. Low serum albumin levels lead

to intestinal mucosa swelling and liquid stool. Infectious diarrhea results from infectious agents

invading the intestinal mucosa. Exudative diarrhea is caused by changes in mucosal integrity,

epithelial loss, or tissue destruction by radiation or chemotherapy. Diarrhea may also be caused

by laxative misuse
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 Diarrhea
Clinic l M nifest tions

• In addition to the increased frequency and fluid content of stools,

the patient usually has abdominal cramps, distention, borborygmus

(i.e., a rumbling noise caused by the movement of gas through the

intestines), anorexia, and thirst. Painful spasmodic contractions of

the anus and tenesmus (i.e., ineffective, sometimes painful straining

with a strong urge) may occur with defecation. Other symptoms

depend on the cause and severity of the diarrhea but are related to

dehydration and to fluid and electrolyte imbalances.

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 Diarrhea
Medic l M n gement
• Management is directed at controlling symptoms, preventing complications,
and eliminating or treating the underlying disease.

• Treatment of diarrhea that is mild or of short duration, such as that caused

by dietary changes or acute illness, involves resting the bowel by limiting

intake to clear liquids for one or two meals and gradually advancing to a

regular diet.

• Fluid and electrolyte replacement by either the oral or intravenous (IV) route
• Dietary adjustments, which may involve eliminating foods that cause diarrhea
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 Diarrhea
Medic l M n gement
• When diarrhea persists and stools are frequent and large, medical

treatment may include: Administration of an antidiarrheal agent, such as

diphenoxylate hydrochloride with atropine sulfate (Lomotil), loperamide

hydrochloride (Imodium), or a combination product such as kaolin and

pectin (Kaopectate)

• Chronic diarrhea depletes the bowel of helpful organisms and allows

yeasts and fungi to thrive unchecked. To recolonize the bowel, capsules

or granules containing Lactobacillus acidophilus are prescribed. These

agents are referred to as probiotics.

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 Diarrhea
Nursing M n gement
• The nurse assesses and monitors the characteristics and pattern of diarrhea. A health history
should address the patient’s medication therapy, medical and surgical history, and dietary

patterns and intake. Reports of recent acute illness or recent travel to another geographic area

are important.

• Assessment includes abdominal auscultation and palpation for tenderness. Inspection of the
abdomen, mucous membranes, and skin is important to determine hydration status. Stool

samples are obtained for testing. The perianal area should also be assessed for skin excoriation.

• During an episode of diarrhea, the patient is encouraged to increase intake of liquids and foods
low in bulk until the symptoms subside. When the patient is able to tolerate food intake, the

patient should avoid caffeine, alcoholic beverages, dairy products, and fatty foods for several

days

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 Disorders of Malabsorption
Description

• The inability of the digestive system to absorb one or more of

the major vitamins (especially A and B12), minerals (i.e., iron and

calcium), and nutrients (i.e., carbohydrates, fats, and proteins)

occurs in disorders of malabsorption.

• Interruptions in the complex digestive process may occur

anywhere in the digestive system and cause decreased

absorption.

 Disorders of Malabsorption
Celi c Dise se
• Celiac disease is a disorder of malabsorption caused by an

autoimmune response to consumption of products that contain the

protein gluten.

• Gluten is most commonly found in wheat, barley, rye, and other grains.
• Celiac disease also has a familial risk component, particularly among
irst-degree relatives. Others at heightened risk include those with type

1 diabetes and Down syndrome. Celiac disease may manifest at any

age in a person who is genetically predisposed.

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 Disorders of Malabsorption
Celi c Dise se

• The most common GI clinical manifestations of celiac disease

include diarrhea, steatorrhea, abdominal pain, abdominal

distention, flatulence, and weight loss.

• It is important that the patient continues to consume gluten

products during testing, or there could be a false negative

serologic inding. The irst serologic test is the immunoglobulin A

(IgA) anti-tissue transglutaminase (tTG), which is 90% sensitive

and 95% speci ic to celiac disease.

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 Disorders of Malabsorption
Celi c Dise se

• Celiac disease is a chronic, non-curable, lifelong disease. There

are no drugs that induce remission; the treatment is to refrain

from exposure to gluten in foods and other products

• The nurse provides patient and family education regarding

adherence to a gluten-free diet, and how to avoid other gluten

products.
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 Disorders of Malabsorption
Celi c Dise se

• Patients must understand how to carefully read labels on both

foods and non-food products to determine if they contain

gluten.
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 Gastrointestinal System
Disorders of the Lower G strointestin l Tr ct
Intestin l nd Rect l disorders

P rt II

Adult Nursing II
Ali T her Moh mmed meen

Mond y, November 2020

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 In lammatory Bowel Disease (IBD)
Description

• IBD is a chronic illness characterized by exacerbations and

remissions. The term IBD refers to several chronic digestive

disorders believed to result from the immune system’s attacking

the bowel. Crohn’s disease and ulcerative colitis are the most

common inflammatory diseases that include IBD. These two

distinct disorders are grouped together because of their similar

symptoms and treatments.

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 In lammatory Bowel Disease (IBD)
Crohn’s Dise se (Region l Enteritis)
• Crohn’s disease is characterized by periods of remission and

exacerbation. It is a subacute and chronic inflammation of the GI tract

wall that extends through all layers (i.e., transmural lesion). Although its

characteristic histopathologic changes can occur anywhere in the GI

tract, it most commonly occurs in the distal ileum and the ascending

colon. Approximately 35% of patients have only ileal involvement

(ileitis), 45% of patients have diseased ileum and colon (ileocolitis), and

20% of patients have only colon involvement (granulomatous colitis)

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 Crohn’s Disease (Regional Enteritis)
P thophysiology nd Etiology

• The cause of Crohn’s disease is unknown.

• The inflammation in Crohn’s disease extends transmurally through
all the layers of the bowel, but the submucosal layer is most

involved. The inflamed areas occur randomly, a phenomenon

described as skip lesions. The bowel is described

as having a ‘‘cobblestone’’ appearance because

of the deep ulcerations that form among the

edematous tissue.
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 Crohn’s Disease (Regional Enteritis)
P thophysiology nd Etiology

• Because Crohn’s disease is a transmural inflammatory process,

inflammation can extend beyond the lining of the bowel. As a

result, inflammatory channels containing blood, mucus, pus, or

stool may develop. Such an inflammatory channel is called a

istula. Fistulae may form a channel between the bowel and the

skin surface (enterocutaneous istulae). Common site for

enterocutaneous istulae is perianal site.

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 Crohn’s Disease (Regional Enteritis)
Clinic l M nifest tions

• The onset of symptoms is usually insidious and the course of

the disease varies in Crohn’s disease, with prominent right lower

quadrant abdominal pain and diarrhea unrelieved by

defecation. Scar tissue and the formation of granulomas

interfere with the ability of the intestine to transport products

of upper intestinal digestion through the constricted lumen,

resulting in crampy abdominal pain.

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 Crohn’s Disease (Regional Enteritis)
Clinic l M nifest tions
• There is abdominal tenderness and spasm. Because eating stimulates
intestinal peristalsis, the crampy pains occur after meals. Chronic

symptoms include diarrhea, abdominal pain, steatorrhea (i.e., excessive

fat in the feces), anorexia, weight loss, and nutritional de iciencies.

• During the physical examination, palpation may reveal an abdominal

mass. Inspection of the perineum and perianal areas may reveal scars

from previous issures, skin tags, or evidence of istulae or perianal

abscesses.
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 Crohn’s Disease (Regional Enteritis)

Di gnostic Findings

• The traditional conclusive diagnostic test for Crohn’s disease

was a barium study of the upper GI tract that showed a “string

sign” on an x-ray image of the terminal ileum, indicating the

constriction of a segment of intestine.

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 Crohn’s Disease (Regional Enteritis)
Medic l M n gement
• Treatment is supportive. The dietary approach varies. A high- iber diet may be indicated
when it is desirable to add bulk to loose stools. A low- iber diet may be indicated in cases

of severe inflammation or stricture.

• TPN may become necessary to provide intestinal rest. IV fluids, electrolytes, and whole
blood are given to correct anemia and restore fluid and electrolyte balance.

• Drug therapy involves supplementary vitamins, iron, antidiarrheal and anti-peristaltic

drugs to reduce peristalsis and rest the bowel, and anti-inflammatory corticosteroids

• Common indications for surgery in patients with Crohn’s disease include recurrent
partial intestinal obstructions; complete intestinal obstructions; intractable istulas; or

intractable abscesses
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 Ulcerative colitis
Description

• Ulcerative colitis is a chronic ulcerative and inflammatory

disease of the mucosal and submucosal layers of the colon and

rectum that is characterized by unpredictable periods of

remission and exacerbation with bouts of abdominal cramps

and bloody or purulent diarrhea. The inflammatory changes

typically begin in the rectum and progress proximally through

the colon
 Ulcerative colitis
P thophysiology nd Etiology
• Although the exact cause is unknown, some believe that multiple factors trigger ulcerative
colitis, including genetic predisposition, infection, allergy, and abnormal immune response.

• Ulcerative colitis affects the super icial mucosa of the colon and is characterized by

multiple ulcerations, diffuse inflammations, and desquamation or shedding of the colonic

epithelium. Bleeding occurs as a result of the ulcerations. The mucosa becomes edematous

and inflamed. The lesions are contiguous, occurring one after the other. Eventually, the

bowel narrows, shortens, and thickens because of muscular hypertrophy and fat deposits.

Because the inflammatory process is not transmural (i.e., it affects the inner lining only),

abscesses, istulas, obstruction, and issures are uncommon in ulcerative colitis

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 Ulcerative colitis
Clinic l M nifest tions
• The onset of the disease usually is abrupt. Clients experience severe diarrhea
and expel blood and mucus along with fecal matter. Cramps and abdominal

pain in the lower left quadrant (LLQ) accompany diarrhea. Eating

precipitates cramping and diarrhea, resulting in anorexia, dehydration, and

fatigue. Clients usually experience weight loss. The urge to defecate may

come so suddenly and with such urgency that the client is incontinent. Some

clients experience such incontinence during sleep. Despite intense tenesmus,

clients may expel very little stool, or they may have 10 to 20 stools per day.

This disease is usually marked by exacerbations and remissions.

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 Ulcerative colitis
Di gnostic Findings
• Colonoscopy is the de initive screening test that can distinguish ulcerative colitis from other
diseases of the colon with similar symptoms.

• Biopsies are typically taken to determine histologic characteristics of the colonic tissue and
extent of disease.

• CT scanning, MRI, and ultrasound studies can identify abscesses and perirectal involvement
• The stool is positive for blood, and laboratory test results reveal low hematocrit and

hemoglobin levels in addition to an elevated white blood cell count, low albumin levels

(indicating malabsorptive disorders), and an electrolyte imbalance. C-reactive protein levels

are elevated. Careful stool examination for parasites and other microbes is performed to rule

out dysentery caused by common intestinal organisms

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 Ulcerative colitis
Medic l nd Surgic l M n gement

• Medical treatment aims toward achieving and maintaining

remission.

• The diet is kept as normal as possible but modi ied to increase

caloric and nutritional content. The client may be given TPN

and intermittent lipid infusions to rest the bowel completely.

• Medications used to treat Crohn’s disease also are used to treat

ulcerative colitis
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 Ulcerative colitis
Medic l nd Surgic l M n gement

• When nonsurgical measures fail to relieve severe symptoms of IBD,

surgery may be necessary.

• Common indications for surgery in patients with ulcerative colitis

include the presence of colon cancer or colonic dysplasia/polyps;

megacolon; severe, intractable bleeding; or perforation

• For the patient with ulcerative colitis, if the surgery is a

proctocolectomy, which is removal of the rectum and colon, the

surgery cures the disease

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Crohn’s disease VS Ulcerative colitis

Crohn’s disease VS Ulcerative colitis
 Nursing Process : Client with IBD
Assessment
• A health history assists in determining the onset, duration, and nature
of the client’s GI problems. Medical, drug, allergy, and diet histories

also are important. Nursing care focuses on monitoring the client for

complications, managing fluid and nutrition replacement, supporting

the client emotionally, and teaching about diet and medications.

• Physical examination includes auscultating and lightly palpating the

abdomen and inspecting the rectal area. The nurse takes vital signs,

weighs the client, and measures and documents intake and output.

 Nursing Process : Client with IBD

Di gnosis

• Diarrhea related to the inflammatory process

• Acute pain related to increased peristalsis and GI inflammation
• De icient fluid volume related to anorexia, nausea, and diarrhea
• Imbalanced nutrition: less than body requirements related to
dietary restrictions, nausea, and malabsorption
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 Nursing Process : Client with IBD

Di gnosis

• Activity intolerance related to generalized weakness

• Anxiety related to impending surgery
• Ineffective coping related to repeated episodes of diarrhea
• Risk for impaired skin integrity related to malnutrition and

diarrhea

• De icient knowledge concerning the process and management of

the disease.
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 Nursing Process : Client with IBD

Pl nning nd Go ls
• The goals for the patient may include relief of pain, reduced anxiety,
maintenance of nutritional requirements, maintain fluid balance, increase

knowledge according to condition, and absence of complications. The

major goals for the patient include attainment of normal bowel

elimination patterns, relief of abdominal pain and cramping, prevention

of fluid volume de icit, maintenance of optimal nutrition and weight,

avoidance of fatigue, reduction of anxiety, promotion of effective coping,

absence of skin breakdown, increased knowledge about the disease

process and self-health management, and avoidance of complications.

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 Nursing Process : Client with IBD
Nursing Interventions
• MAINTAINING NORMAL ELIMINATION PATTERNS
• The nurse assists the patient in determining if there is a relationship
between diarrhea and certain foods, activities, or emotional stressors.

Identifying precipitating factors, the frequency of bowel movements, and

the character, consistency, and amount of stool passed is important. It is

important to administer antidiarrheal medications as prescribed.

Loperamide may be prescribed 30 minutes before meals. The nurse

should record the frequency and consistency of stools after therapy is

initiated.

 Nursing Process : Client with IBD

Nursing Interventions
• RELIEVING PAIN
• The character of the pain is described as dull, burning, or crampy. It is
important to ask about its onset. Does it occur before or after meals,

during the night, or before elimination? Is the pattern constant or

intermittent? Is it relieved with medications?

• The nurse administers analgesic agents as prescribed for pain.

Position changes, local application of heat (as prescribed), diversional

activities, and prevention of fatigue also are helpful for reducing pain.

 Nursing Process : Client with IBD

Nursing Interventions
• MAINTAINING FLUID INTAKE
• To detect fluid volume de icit, the nurse keeps an accurate record of I&O.
The nurse monitors daily weights for fluid gains or losses and assesses the

patient for signs of fluid volume de icit (i.e., dry skin and mucous

membranes, decreased skin turgor, oliguria, fatigue, decreased temperature,

increased hematocrit, elevated urine speci ic gravity, and hypotension). It is

important to encourage oral intake of fluids and to monitor the flow rate of

any IV fluids. The nurse initiates measures to decrease diarrhea (e.g., dietary

restrictions, stress reduction, antidiarrheal agents).

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 Nursing Process : Client with IBD
Nursing Interventions
• MAINTAINING OPTIMAL NUTRITION
• Parenteral nutrition is indicated in patients who have Crohn’s disease with
severe malnutrition and intolerance to enteral nutrition and who are expected

to likely remain intolerant to enteral nutrition for more than 1 to 2 weeks.

• If oral foods are tolerated, small, frequent, low-residue feedings are given to
avoid over distending the stomach and stimulating peristalsis. The patient

must restrict activity to conserve energy, reduce peristalsis, and reduce

caloric requirements.

 Nursing Process : Client with IBD

Nursing Interventions
• REDUCING ANXIETY
• Rapport can be established by being attentive and displaying a calm, con ident
manner. The nurse allows time for the patient to ask questions and express

feelings. Careful listening and sensitivity to nonverbal indicators of anxiety (e.g.,

restlessness, tense facial expressions) are helpful. The patient may be emotionally

labile because of the consequences of the disease and the uncertainty of

exacerbations with complications. The nurse tailors information about possible

impending surgery to the patient’s level of understanding and desire for detail. If

surgery is planned, pictures, illustrations, websites, and blogs help explain the

surgical procedure and help the patient visualize what a stoma looks like.

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 Gastrointestinal System
Disorders of the Lower G strointestin l Tr ct
Intestin l nd Rect l disorders

P rt III

Adult Nursing II
Ali T her Moh mmed meen

Mond y, November 2020

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 Irritable Bowel Syndrome (IBS)
De ine

• Irritable bowel syndrome (IBS) is a chronic functional motility

disorder characterized by recurrent abdominal pain (a cluster of

symptoms), despite the absence of an identi iable disease

process associated with disordered bowel

movements, which may include diarrhea,

constipation, or both (predominates

manifestation).
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 Irritable Bowel Syndrome (IBS)
P thophysiology nd Etiology
• Fluctuating intestinal motility tends to be an underlying factor that causes
symptoms. Changes in motility may result from a neuroendocrine

dysregulation involving the autonomic nervous system. This affects motor

function in the GI tract through neuron stimulation and inhibition, influencing

bowel motility. When a parasympathetic neurotransmitter (e.g., acetylcholine)

is released, intestinal motility increases and diarrhea results. An opposite

effect occurs when the smooth muscle of the gut responds to sympathetic

neuro- transmission. Other factors may also be involved, such as infection or

irritation, as well as disturbances in vasculature of the bowel or metabolism

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 Irritable Bowel Syndrome (IBS)
Clinic l M nifest tions
• Symptoms can vary widely, ranging in intensity and duration from mild and

infrequent to severe and continuous. The main symptom is an alteration in bowel

patterns: constipation (classi ied as IBS-C), diarrhea (classi ied as IBS-D), or a

combination of both (classi ied as IBS-M for “mixed”). The few patients with IBS

who do not it any of these three categories of IBS-C, IBS-D, or IBS-M, are

classi ied as IBS-U for “unknown.” Pain, bloating, and abdominal distention often

accompany changes in bowel pattern. Many clients suffer with belching and

flatulence (intestinal gas).

• The abdominal pain is sometimes precipitated by eating and is frequently relieved

by defecation.
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 Irritable Bowel Syndrome (IBS)
Di gnostic Findings

• Radiographic and endoscopic tests rule out other disorders

with similar symptoms

• By investigations
• Speci ically, a barium enema and colonoscopy may show the
spasms, distention, and mucus accumulations associated with

IBS
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 Irritable Bowel Syndrome (IBS)

Di gnostic Findings
• By clinical manifestations
• The clinical manifestations of IBS must be present sometime during the
last 3 months with onset for at least 6 months prior to diagnosis. These

manifestations include recurrent abdominal pain for at least one day

weekly that is associated with 2 or more of the following:

• Abdominal pain related to defecation;

• Abdominal pain associated with a change in frequency of stool;
• Abdominal pain associated with a change in form/appearance of stool
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 Irritable Bowel Syndrome (IBS)

Medic l M n gement

• The goals of treatment are to relieve abdominal pain and control

diarrhea or constipation. Lifestyle modi ication, including stress

reduction, ensuring adequate sleep, and instituting an exercise

regimen, can result in symptom improvement.

• For patients with IBS-D, antidiarrheal agents (e.g., loperamide, for

chronic alosetron and rifaximin) may be given to control the

diarrhea and fecal urgency. Lubiprostone (Amitiza), can be

prescribed for patients with IBS-C.

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 Irritable Bowel Syndrome (IBS)

Nursing M n gement
• The nurse’s role is to provide patient and family education and encourage self-care activities.
The nurse may provide education on the appropriate use of a bowel habit diary. The nurse

emphasizes and reinforces good sleep habits and good dietary habits (e.g., avoidance of food

triggers). Restriction and then gradual reintroduction of foods that are possibly irritating may

help determine what types of food are acting as irritants (e.g., beans, caffeinated products,

corn, wheat, dairy lactose, fried foods, alcohol, spicy foods, aspartame(sweetener)).

• A good way to identify problem foods is to keep a 1- to 2-week food diary. Patients are
encouraged to eat at regular times and to avoid food triggers. They should understand that

although adequate fluid intake is necessary, fluid should not be taken with meals because this

results in abdominal distention. Alcohol use and cigarette smoking are discouraged. Stress

management via relaxation techniques and exercise can be recommended.

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Acute Abdominal In lammatory Disorders

Introduction

• An acute abdomen, sometimes called a surgical abdomen is

characterized by an acute onset of abdominal pain that does not

have a traumatic etiology and that most typically requires swift

surgical intervention to prevent peritonitis, sepsis, and septic

shock.

• Appendicitis and peritonitis are among disorders known as acute

abdominal inflammatory disorders.

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 Peritonitis
Description
• Peritonitis is inflammation of the peritoneum, which is the serous

membrane lining the abdominal cavity and covering the viscera. Usually,

it is a result of bacterial infection but may occur secondary to a fungal or

mycobacterial infection; the organisms come from diseases or disorders

of the GI tract or, in women, from the internal reproductive organs (e.g.,

fallopian tube). The most common bacteria implicated are Escherichia

coli and Klebsiella, Proteus, Pseudomonas, and Streptococcus species.

Peritonitis can also result from external sources such as abdominal

surgery or trauma (e.g., gunshot wound, stab wound)

 Peritonitis
Description
• Peritonitis can be categorized as:
• Primary peritonitis, also called spontaneous bacterial peritonitis (SBP), occurs as a

spontaneous bacterial infection of ascitic fluid. This occurs most commonly in adult

patients with liver failure.

• Secondary peritonitis occurs secondary to perforation of abdominal organs with spillage

that infects the serous peritoneum. The most common causes include a perforated

appendix, and perforated peptic ulcer,.

• Tertiary peritonitis occurs as a result of a suprainfection in a patient who is

immunocompromised. Tuberculous peritonitis in a patient with AIDS is an example of

tertiary peritonitis; these are rare causes of peritonitis.

 Peritonitis
Clinic l M nifest tions
• Symptoms include severe abdominal pain, distention, tenderness, nausea,
and vomiting. Fever may be absent initially, but the temperature rises as

infection becomes established.

• The client avoids moving the abdomen when breathing because

movement increases pain. He or she may draw the knees up toward the

abdomen to lessen the pain. Lack of bowel motility typically accompanies

peritonitis. The abdomen feels rigid and boardlike as it distends with gas

and intestinal contents. Bowel sounds typically are absent.

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 Peritonitis
Di gnostic indings

• An abdominal x-ray may show air and fluid levels as well as

distended bowel loops. Abdominal ultrasound may reveal

abscesses (localized collection of purulent material surrounded

by inflamed tissues) and fluid collections, and ultrasound-guided

aspiration may assist in easier placement of drains.

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 Peritonitis
Nursing M n gement

• The nurse monitors the acutely ill client while completing

preparations for diagnostic tests or surgery. He or she

administers analgesics and infuses IV fluids with secondary

administrations of antibiotics. If ordered, a nurse passes a

nasogastric tube and connects it to suction. The client may need

a urinary retention catheter. The nurse assesses the circulatory

status by taking vital signs frequently and monitoring central

venous and pulmonary artery pressures.

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 Appendicitis
Descriptions

• The appendix is a small, vermiform (i.e., wormlike) appendage

about 8 to 10 cm long that is attached to the cecum just below

the ileocecal valve. The appendix ills with products of digestion

and empties regularly into the cecum.

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 Appendicitis
Di gnostic Findings
• Diagnosis is based on the results of a complete history and physical examination
and on laboratory indings and imaging studies.

• The CBC demonstrates an elevated white blood cell count with an elevation of
the neutrophils. C-reactive protein levels are typically elevated.

• A CT scan may reveal a right lower quadrant density or localized distention of the
bowel; enlargement of the appendix by at least 6 mm is suggestive of appendicitis.

• A pregnancy test may be ordered for women of childbearing age to rule out
ectopic pregnancy and before radiologic studies are done. A urinalysis is usually

obtained to rule out urinary tract infection or renal calculi

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 Appendicitis
Di gnostic Findings
By Physical examination

• the pain localizes in the RLQ at McBurney’s point, an area midway

between the umbilicus and the right iliac crest. Often, the pain is

worse when manual pressure near the region is suddenly released, a

condition called rebound tenderness.

• When an examiner deeply palpates the left lower abdominal

quadrant, and the client feels pain in the RLQ, this is referred to as a

positive Rovsing’s sign and suggests acute appendicitis.

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 Appendicitis
Nursing M n gement
• Goals include relieving pain, preventing fluid volume de icit, reducing anxiety, preventing or
treating surgical site infection, preventing atelectasis, maintaining skin integrity, and attaining

optimal nutrition.

• The nurse prepares the patient for surgery, which includes an IV infusion to replace fluid loss
and promote adequate renal function, antibiotic therapy to prevent infection, and

administration of analgesic agents for pain (if prescribed).

• After surgery, the nurse places the patient in a high Fowler position. This position reduces the
tension on the incision and abdominal organs, helping to reduce pain. It also promotes

thoracic expansion, diminishing the work of breathing, and decreasing the likelihood of

atelectasis. The patient is educated on the use of an incentive spirometer and encouraged to

use it at least every 2 hours while awake.

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 Th nks for your interest

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