Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of lower GI disorders
- Describe the diagnostics for and laboratory values monitored in the management of lower GI disorders
- Apply nursing concepts and plan associated nursing care for the patient with lower GI disorders
- Evaluate the efficacy of nursing care for patient with lower GI disorders
- Describe the medical therapies that apply to the care of the patient with lower GI disorders
This section focuses on common alterations in function of the large intestines. These alterations result in common symptoms of several diseases and conditions of the GI system that can impede proper absorption of nutrients and elimination of stool. After upper GI digestion, the muscles of the small intestine push the contents onward for further digestion in the lower GI tract. Bacteria in the GI tract, called normal flora make up part of the microbiome, which is all of the microorganisms in the GI tract. These normal flora assist with digestion. As peristalsis continues, the waste products of the digestive process move into the large intestine. The large intestine absorbs water and changes the waste from liquid into stool. The rectum, at the lower end of the large intestine, stores stool until it is pushed out of the anus during a bowel movement.
Constipation
Constipation is difficult or infrequent passage of stools associated with hard, dry feces. Typically, a patient is diagnosed with constipation if they have fewer than three bowel movements per week.
Pathophysiology
Constipation can be caused by slowed peristalsis due to decreased activity, dehydration, lack of fiber, medications like opioids, depression, or surgical procedures in the abdominal area. As the stool moves slowly through the large intestine, additional water is reabsorbed, resulting in the stool becoming hard, dry, and difficult to move through the lower intestines.
Clinical Manifestations
The patient may experience associated symptoms, such as rectal pressure, abdominal cramps, bloating, distension, and straining. In more serious cases, constipation can be a sign of fecal impaction, intestinal obstruction, or paralytic ileus. A fecal impaction is a blockage that occurs when stool accumulates in the rectum, usually due to the patient not feeling the presence of stool or not using the toilet when the urge is felt. An intestinal obstruction is a partial or complete blockage of the intestines so that contents of the intestine cannot pass through.
When peristalsis is not propelling the contents through the intestines or when there is a obstruction, such as severe fecal impaction, paralytic ileus may result. Patients who have undergone abdominal surgery or received general anesthesia are at increased risk. Other risk factors include the chronic use of opioids, electrolyte imbalances, bacterial or viral infections of the intestines, decreased blood flow to the intestines, or kidney or liver disease.
If an obstruction blocks the blood supply to the intestine, infection and tissue death (gangrene) can result. Symptoms of an intestinal obstruction or paralytic ileus include
- abdominal distention or a feeling of fullness
- abdominal pain or cramping
- constipation
- diarrhea
- frequent belching
- inability to pass gas
- vomiting
Because of the common occurrence of paralytic ileus in postoperative patients, nurses routinely monitor for these symptoms, and diet orders are not upgraded until the patient is able to pass gas (Phillips, 2022).
Assessment and Diagnostics
The nurse will complete a history and a physical assessment. The history will include the last time the patient had a bowel movement and the usual frequency and consistency of bowel movements. The patient’s medications need to be examined for the potential of constipation. Physical assessment may reveal a tender abdomen, and stool may be palpated in the lower abdomen.
Nursing Care of the Patient with Constipation
The goal of interventions to treat constipation is to establish what is considered a normal bowel pattern for each patient and to set an expected outcome of a bowel movement at least every 72 hours, regardless of intake.
Recognizing Cues and Analyzing Cues
The prevailing cue during an assessment will be the lack of ability to have a bowel movement. There may be accompanying abdominal cramping, abdominal distention, or discomfort. The nurse may find contributing history or medications.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
The nurse will hypothesize that the patient has constipation. The exact intervention will depend on the setting and the patient’s preferences. The patient may drink a hot beverage, which may stimulate peristalsis. Fiber may be added to the diet. Finally, a laxative may be used. These are available in pill form, liquid form, and as suppositories. The patient can use an enema if not contraindicated by other medical conditions such as fluid and electrolyte imbalances, cardiac history, immunocompromise, or suspected bowel perforation.
In cases of paralytic ileus, treatment may include insertion of an NG tube attached to suction to help relieve abdominal distention and vomiting until peristalsis returns. Obstructions may require surgery if the tube does not relieve the symptoms or if there are signs of tissue death.
Evaluation of Nursing Care and Outcomes for the Patient with Constipation
A successful outcome is the patient having a bowel movement. The nurse should support the patient and help develop an appropriate treatment plan. The goals evaluated may be, for example, the patient will have a bowel movement by (set a time), and the patient will verbalize a plan to prevent further constipation episodes.
The nurse will evaluate the outcomes of care. A bowel movement would indicate that treatment interventions were successful. If the patient is still struggling to have a bowel movement, further collaboration and modification of interventions may be needed.
Medical Therapies and Related Care
Treatment typically includes a prescribed daily bowel regimen, such as oral stool softeners (e.g., docusate) and a mild stimulant laxative (e.g., a sennoside). Stronger laxatives (e.g., magnesium hydroxide [e.g., Milk of Magnesia] or bisacodyl), rectal suppositories, or enemas are implemented when oral medications are not effective.
Diarrhea
Diarrhea is defined as having more than three unformed stools in 24 hours. The Bristol Stool Form Scale may be used to assess the characteristics of stools. Diarrhea can cause dehydration, skin breakdown, and electrolyte imbalances.
Link to Learning
Read this article about the development of a new version of the Bristol Stool Form Scale for assessing stool.
Pathophysiology
Diarrhea is caused by increased peristalsis causing the stool to move too quickly through the large intestines for water to be effectively reabsorbed, resulting in loose, watery stools.
Many conditions can cause diarrhea, such as infectious processes, food poisoning, medications, food intolerances, allergies, anxiety, and medical conditions. Patients are at risk for dehydration due to this water loss.
Clinical Manifestations
An individual with diarrhea will present with frequent bowel movements accompanied by the need for immediate toileting, abdominal cramping, and, perhaps, nausea. Dehydration symptoms may be present, such as urinating less than usual, fatigue, thirst, and light-headedness, and an elevated temperature if the patient is infectious.
Diagnostics and Laboratory Values
The provider will determine diagnostic testing based primarily upon medical history and physical examination. Bloodwork may be done to rule out conditions that can cause diarrhea, such as certain diseases, conditions, or infections. Monitor the patient’s electrolyte levels because diarrhea can cause electrolyte deficiencies. A stool specimen may be checked for the presence of blood, bacteria, or parasites. If food intolerance or food allergy is suspected, such as lactose intolerance or celiac disease, diet modifications may be recommended to see if symptoms improve. Diagnostic testing, such as endoscopy, colonoscopy, or flexible sigmoidoscopy, may be done to see if the diarrhea is from a structural issue in the digestive tract. Biopsies may be performed of the GI tract during these procedures to rule out cancer or other cell abnormalities.
Nursing Care of the Patient with Diarrhea
Maintaining adequate fluid intake is the priority of care for a patient with diarrhea. Nurses should administer IV fluids as ordered and encourage oral intake of fluids.
Recognizing Cues and Analyzing Cues
The nurse providing care to a patient with diarrhea uses both objective and patient-reported data to optimize care. The patient may report feeling thirsty along with having frequent loose stools. Assessment of skin turgor may revel dehydration, and hyperactive bowel sounds may be heard on auscultation. Vital signs should be completed with a focus on blood pressure and heart rate to monitor for dehydration (Table 19.6).
| Degree | Signs and Symptoms |
|---|---|
| Mild to moderate | Increased thirst Dry mucus membrane Low urine output Dark, concentrated urine Dry, cool skin Headache Muscle cramps |
| Moderate to severe | Low or absent urine output Very dry skin Dizziness Tachycardia Tachypnea Hypotension Sunken eyes Sleepiness, lack of energy, confusion or irritability Fainting |
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Signs of dehydration are a high priority. Monitor laboratory values for electrolyte depletion and report abnormalities to the practitioner. The nurse will anticipate administering over-the counter antidiarrheal products, if appropriate, and encourage fluids.
Evaluation of Nursing Care and Outcomes for the Patient with Diarrhea
Symptom improvement and prevention of complications are signs of effective nursing care. The nurse evaluates how often the patient is having bowel movements to see if there is improvement in the consistency and frequency of stools. Evaluation of vital signs can help determine if the patient has adequate fluid balance. The primary outcome is resolution of the diarrhea and return to normal fluid balance. The nurse evaluates trends in the patient’s intake and output, vital signs, and electrolytes to assess care.
Medical Therapies and Related Care
Treatment of diarrhea includes promoting hydration with water or other fluids (e.g., electrolyte-containing drinks) that improve electrolyte status. IV fluids may be required if the patient becomes dehydrated. Medications, such as loperamide, psyllium, and anticholinergic agents, may be prescribed to treat diarrhea that is causing dehydration. In some cases, rectal tubes may be prescribed to collect watery stool, but strict monitoring is required due to possible damage to the rectal mucosa.
Irritable Bowel Syndrome
A disorder called irritable bowel syndrome (IBS) affects the large intestine and causes changes in bowel movements and abdominal pain. It is the most commonly diagnosed GI disorder in the United States, with 10% to 15% of the population being affected (Patel & Shackelford, 2022), and can be broken down into more specific diagnoses: IBS-D (with diarrhea), IBS-C (with constipation), or IBS-M (with mixed bowel patterns).
Pathophysiology and Clinical Manifestations
The exact cause of IBS is unclear. It can occur after infection, be triggered by stress, or be caused by food intolerances, brain-gut interaction, and inflammatory processes (Figure 19.13).
IBS primarily presents with diarrhea and/or constipation with abdominal pain. Other symptoms include abdominal pain, cramps, gas, boating, and fullness. Pain usually increases when bowel habits change and subsides after a bowel movement.
Assessment and Diagnostics
A focused assessment on GI signs and symptoms, stressors, food intolerances, and related factors would be completed. Without any alarming findings, such as iron deficiency, weight loss, or hematochezia (passage of fresh blood in stool), diagnostic testing is not usually done. Serum studies to rule out infection or other disease may be performed.
Nursing Care of the Patient with IBS
The nursing care of a patient with IBS will be focused on ongoing physical assessments, creating a plan with the patient, and implementing the measures. An evaluation process will be completed with the patient.
Recognizing Cues and Analyzing Cues
The nurse will complete the history and physical assessment. The findings will be nonspecific, such as abdominal pain and constipation or diarrhea. The patient may have a history of mucus in the stool. Focused patient history information should include stool frequency, amount, and any precipitating factors. This may help determine what part of the intestines is affected.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Ulceration, vascular engorgement, and highly vascular granulation tissue can put the patient at risk for complications, such as perforation and bleeding. Signs and symptoms to report to the provider include fever, lethargy, tachycardia, and increased anxiety. Provide pain management as appropriate and monitor serum blood electrolyte and CBC values closely.
Evaluation of Nursing Care and Outcomes for the Patient with IBS
Nursing care for patients with IBS is driven primarily by symptom improvement as reported by the patient. Vital signs and laboratory values should show adequate fluid balance. The nurse will evaluate how often the patient is experiencing symptoms to see if interventions have caused symptom improvement. A decrease in pain medication use is another indication that symptoms are improving.
Medical Therapies and Related Care
Because IBS is a symptom-based disorder, treatment is aimed at symptom resolution. A combination of anticholinergics, antidepressants, antibiotics, fiber supplements, laxatives, and/or antidiarrheals may be ordered, depending on patient symptoms (Patel & Shackelford, 2022). Increased physical activity and dietary changes may also be recommended.
Celiac Disease
An autoimmune disorder, celiac disease is triggered by gluten ingestion, which causes damage to the small intestine; gluten is a protein found in the wheat plant and other grains, such as barley and rye. Approximately 1 percent of the population is affected by celiac disease (Celiac Disease Foundation, n.d.). It is hereditary and can occur at any age and any time after gluten has been consumed.
Pathophysiology
In patients with celiac disease, the ingestion of gluten causes the body’s immune system to attack the villi (small, finger-like cells that absorb nutrients) of the small intestine. This results in permanent damage over time, causing a scalloping of the folds and a cracked appearance of the mucosa, and disrupts the absorption of nutrients (Figure 19.14). The causes are unknown, and it is present when people with a genetic predisposition consume gluten.
Clinical Manifestations
Patients with celiac disease present with GI symptoms, including
- abdominal pain
- bloating
- chronic diarrhea
- constipation
- gas
- lactose intolerance
- nausea
- vomiting
- weight loss
Other symptoms may include fatigue, anxiety, depression, bone or joint pain, canker sores, dry mouth, or itchy rash (NIH, 2023).
Assessment and Diagnostics
Assessment will focus on the GI symptoms and detailed patient history. Diagnostic workup will include serologic studies focused on antibodies associated with celiac disease. A duodenal mucosal biopsy will confirm diagnosis. Other diagnostic tests may be completed and laboratory values evaluated to assess for complications such as vitamin deficiencies, electrolyte imbalances, anemia, or bleeding.
Nursing Care of the Patient with Celiac Disease
The nursing care of the patient with celiac disease is focused on education about a gluten-free diet (Table 19.7), identifying symptoms, and evaluating medication side effects and effectiveness.
| Type of Food | Example |
|---|---|
| Gluten containing | Barley, farina, farro, rye, semolina, spelt, and wheat (e.g., durum, einkorn, emmer, graham flour, Khorasan wheat), including triticale (a blend of wheat and rye) and wheat berries |
| Gluten free | Amaranth, arrowroot, beans, buckwheat groats (also known as kasha), cassava, chia, corn, flax, gluten-free oats, millet, nut flours, potato, quinoa, rice, sorghum, soy, tapioca, teff, yucca |
It is important to educate the patient about the importance of reading food labels. For instance, oats are naturally gluten-free but may be contaminated when grown or processed in an area that also processes gluten-containing foods.
Recognizing Cues and Analyzing Cues
Often, symptoms of celiac disease are nonspecific. They can include abdominal pain, bloating, gas, diarrhea, weight loss, depression, fatigue, headaches, joint pain, nausea, and vomiting. A physical assessment may reveal skin rash, peripheral neuropathy, mouth ulcers, or canker sores. Vital signs should be completed with a focus on blood pressure and heart rate, especially in the patient having diarrhea, to evaluate for signs of dehydration, such as tachycardia and hypotension.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Patients with celiac disease often have malabsorption. Signs and symptoms of malabsorption include steatorrhea (fatty stools), diarrhea, and weight loss. Nurses will review results of laboratory values and administer vitamin, electrolyte, and/or mineral repletion as ordered. IV fluids may be administered to correct dehydration.
Evaluation of Nursing Care and Outcomes for the Patient with Celiac Disease
Goals for taking care of the patient with celiac disease are symptom improvement and patient education about diet modification. With symptom improvement and patient education in mind, the nurse should monitor the frequency and severity of symptoms as reported by the patient. Laboratory values and intake and output should be balanced. The patient should be able to name gluten-containing foods to avoid and understand the importance of diet adherence to prevent further disease progression.
Medical Therapies and Related Care
Treatment is a lifelong, strict, gluten-free diet. Diet maintenance will prevent symptoms from returning, as well as prevent complications, such as malabsorption, anemia, bone weakening, infertility and miscarriage, lactose intolerance, cancer, seizures, or peripheral neuropathy (Mayo Clinic, 2023).
Colorectal Cancer
Cancer with an origin in the colon or rectal tissue is called colorectal cancer. It accounts for about 8 percent of all new cancer cases in the United States annually and has a 5-year survival rate of 65% (National Cancer Institute, 2023). Because of an increased emphasis on prevention screening, colorectal cancer is often detected before symptoms occur. Patients who present with symptoms usually have advanced disease.
Link to Learning
The U.S. Preventive Services Task Force developed colorectal cancer screening recommendations based on a patient’s age and medical history in order to detect cancer at an early stage.
Pathophysiology
Abnormal or mutated cells that the immune system is unable to eliminate begin to grow on the tissue of the colon or rectum. These cells then begin to multiply. Colorectal cancer is caused by genetic factors, diet, and inflammatory conditions of the GI tract.
Clinical Manifestations
Patients with colorectal cancer may present with a change in bowel habits, bloody stools, unexplained weight loss, fatigue, gas pains, bloating, or abdominal cramping. Patients may have a history of colorectal polyps, a genetic condition such as Lynch syndrome, chronic inflammatory bowel disease, heavy alcohol use, obesity, smoking, or a family history of colorectal cancer.
Assessment and Diagnostics
Assessment may be nonspecific or may demonstrate GI symptoms, such as abdominal tenderness, a palpable abdominal mass, rectal bleeding, ascites, or hepatomegaly (Dragovich, 2023). A rectal examination and colonoscopy with biopsy will enable the health care provider to diagnose colorectal cancer. Other serum studies, such as CBC count, complete metabolic panel, and liver function studies, may be done to assess organ function (Dragovich, 2023). Imaging, such as CT and MRI scans of the abdomen and pelvis, is obtained for staging purposes.
Nursing Care of the Patient with Colorectal Cancer
Nursing care of the patient with colorectal cancer is focused on symptom management, pain relief, and prevention of complications. Collaboration with the interdisciplinary team is important to optimize care. The nurse will assist with preparing the patient for surgery, provide education about adjunct therapies prescribed, manage side effects, and administer palliative therapy, if appropriate. Patients with a stoma (see 19.7 Ostomy Care) may experience body image disturbances, and the nurse will have to help the patient manage self-esteem issues during treatment.
Recognizing Cues and Analyzing Cues
Patients with colorectal cancer will present with nonspecific GI signs and symptoms, such as a change in bowel habits, bloody stools, diarrhea, constipation, abdominal pain, unexplained weight loss, and fatigue. Vital signs may reveal hypotension or tachycardia in patients who are dehydrated. The patient may also have abdominal pain on palpation and poor skin turgor.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Signs of infection are a priority when caring for the patient with colorectal cancer. The nurse may frequently assess the patient’s temperature, vital signs, pain level, surgical incision(s), and IV access site to monitor for infection, especially if the patient is receiving chemotherapy. Patient education topics include maintaining a clean environment, signs and symptoms of infection to report to the nurse or provider, and staying away from family and friends who are sick.
Evaluation of Nursing Care and Outcomes for the Patient with Colorectal Cancer
Evaluation of nursing care will be based on treatment preferences and patient goal preferences. Symptom improvement, decrease in pain, and prevention of complications are all signs of effective nursing care. A patient with colorectal cancer may have dysfunctional GI motility as a side effect of the disease process and treatment. The patient remaining free of signs and symptoms of GI motility dysfunction (e.g., distention, cramping, pain) and maintaining normal bowel sounds and regular formed stools would indicate that the outcomes have been reached. If the patient continues to have signs and symptoms of GI motility dysfunction, interventions may need adjustment.
Medical Therapies and Related Care
Most cases of colorectal cancer require surgical intervention (Figure 19.15). Chemotherapy may be used in adjunct with surgery in patients with advanced disease. Radiation therapy is used for palliative purposes in certain cases of metastasis.
Appendicitis
Inflammation of the appendix is called appendicitis. It occurs more often in men and is most common in people aged 10 to 30 years (Jones et al., 2023). It occurs acutely without warning.
Pathophysiology
Appendicitis is most often caused by an obstruction within the appendiceal orifice. This creates an inflammatory response, which can lead to local ischemia and perforation. Perforation causes the spilling of bacteria and bowel contents into the peritoneal cavity, causing a contained abscess or peritonitis. When peritonitis is left untreated, it can lead to fatal complications, such as sepsis and septic shock.
Link to Learning
Watch this video for an explanation about the pathophysiology of appendicitis as well as examination, diagnosis, and treatment.
Clinical Manifestations
A patient with appendicitis will present with right lower quadrant or periumbilical pain. The patient may also report anorexia, nausea, vomiting or diarrhea, fever malaise, and urinary frequency or urgency.
Assessment and Diagnostics
An initial abdominal assessment will reveal right lower quadrant pain. A positive Rovsing sign (palpation of the left lower quadrant worsens right lower quadrant pain) is also an indicator of appendicitis. The patient may also have a fever, tachycardia, and tachypnea.
Common signs of acute peritonitis found during a physical assessment are:
- guarding: the patient consciously tenses the abdominal muscles in anticipation of pain
- rebound tenderness: pain that occurs after the removal of manual pressure to the abdomen
- rigid abdomen: stiffness of the abdominal muscles that the patient cannot relax
Other signs of peritonitis are fever, fluid in the abdomen, chills, abdominal distention and pain, constipation, and vomiting. Bloodwork and imaging can confirm appendicitis. The patient’s white blood cell (WBC) count may be elevated, indicating infection. Ultrasound or CT scan of the abdomen may be performed for diagnosis or to visualize the extent of disease. Diagnostic tests for peritonitis include blood, urine, x-ray, and CT imaging.
Interdisciplinary Management
The patient will most likely need surgical removal of the appendix, called appendectomy. This can be done laparoscopically or by open surgery, depending on the severity of disease. Antibiotics will be given to treat infection. IV fluids may be necessary of the patient has to remain NPO for a time. Interdisciplinary care will involve the nurse, provider, surgeon, nutritionist, and infectious disease provider.
Treatment for peritonitis depends on the severity of the infection, and can range from IV antibiotics, surgery, medications for organ support, IV fluids, or a combination of treatments (Jones et al., 2023)
Diverticular Disease
The condition diverticulosis is the asymptomatic presence of diverticula, or sac-like protrusions, on the walls of the large intestine (Figure 19.16). Diverticulosis occurrence is 20% in adults aged 40 to 60 years, but up to 60% after the age of 60 (Pemberton & Strate, 2023). When diverticulosis becomes symptomatic, diverticular disease occurs; it is estimated to occur in 25% of people with diverticulosis (Tursi et al., 2020). A similar term, diverticulitis, refers to inflammation of the diverticula. The inflammation can remain contained or spread from the perforation to cause peritonitis.
Pathophysiology
Although the exact pathophysiology of diverticular disease is unknown, it is thought to have various manifestations. Connective tissue abnormalities in the intestine are thought to be the cause of development of asymptomatic diverticulosis. Gut microbial changes and certain medications are believed to cause acute diverticulitis and diverticular hemorrhage. The disease can be acute or chronic. Risk factors for diverticulosis include older age, male sex, smoking history, and higher BMI.
Clinical Manifestations
Patients with diverticular disease may present with nonspecific GI symptoms such as lower abdominal pain, bloating, and diarrhea. In severe cases, fever or bloody stools may be present.
Assessment and Diagnostics
Subjective and objective data are gathered, and any clinical manifestations are noted. A physical assessment may reveal abdominal pain on palpation. Routine testing, such as bloodwork, urinalysis, and stool testing, may be done to narrow down a cause for symptoms. A CT scan of the abdomen can show any inflammation in the intestines. A colonoscopy and sigmoidoscopy can show the pockets of inflammation and disease within the intestines.
Interdisciplinary Management
In some cases, mild disease may resolve on its own. The interdisciplinary team, including the nurse, gastrointestinal provider, and nutritionist, work together to develop a treatment plan. Treatment may include
- a liquid diet to rest the intestines, reduce inflammation, and promote healing
- antibiotics, if infection is the suspected cause
- over-the-counter pain relief
If there is active bleeding in the intestines, the patient may need blood transfusions. If the bleeding does not resolve, surgical intervention may be necessary. Abscess drainage may be performed by a radiologist using local anesthesia. In serious instances, a fistula (a hole in the wall of the intestine) may occur. This requires surgical intervention to remove the section of the colon involved.
Read the Electronic Health Record
Caring for a Patient with Abdominal Pain
Patient Information
Name: Johanna Dear
Age: 65 years
Sex: Female
Chief complaint:
- Severe abdominal pain, primarily in the lower left quadrant, for the past 48 hours
- Diagnosed with diverticular disease 5 years ago.
- History of hypertension, well-controlled with medication
- Previous episodes of mild diverticulitis, treated successfully with antibiotics
- Temperature: 101.3°F (38.5°C)
- Heart rate: 95 bpm
- Blood pressure: 140/85 mm Hg
- Respiratory rate: 20 breaths per minute
- Oxygen saturation: 98% on room air
- WBC count: 14,000 /µL (elevated)
- Hemoglobin: 13.5 g/dL (normal)
- Hematocrit: 40.5% (normal)
- Platelets: 250,000 /µL (normal)
- C-reactive protein (CRP): 50 mg/L (elevated)
- Electrolytes:
- Sodium: 138 mmol/L (normal)
- Potassium: 4.0 mmol/L (normal)
- Chloride: 102 mmol/L (normal)
- Bicarbonate: 22 mmol/L (normal)
- Blood urea nitrogen: 18 mg/dL (normal)
- Creatinine: 1.0 mg/dL (normal)
- CT scan of abdomen and pelvis: Findings consistent with acute diverticulitis. Presence of inflamed diverticula in the sigmoid colon with pericolonic fat stranding. No abscess or free air noted.
- Patient reports increased severity of abdominal pain and tenderness over the past 2 days.
- Appetite has decreased, and he has experienced occasional nausea.
- No vomiting, diarrhea, or changes in bowel habits reported.
- Patient has been compliant with hypertension medications.
- Mild fever observed upon admission.
- Lisinopril 10 mg daily (for hypertension)
- Acetaminophen 500 mg every 6 hours as needed for pain
- Ciprofloxacin 500 mg twice daily
- Metronidazole 500 mg three times daily
Inflammatory Bowel Disease
Chronic inflammation of the GI tract is called inflammatory bowel disease (IBD). The two main types of IBD are Crohn’s disease and ulcerative colitis. Crohn’s disease (CD) is inflammation that can occur in multiple layers of the bowel, in any segment of the GI tract. The second main type, ulcerative colitis (UC), is inflammation that occurs only in the innermost wall of the large intestine and colon. IBD occurs in 1.3% of adults in the United States (CDC, 2022a) and most often in people aged 15 to 30 years old (McDowell et al., 2023).
Pathophysiology
Chronic mucosal inflammation in the GI tract occurs in IBD, leading to edema, bleeding, ulcers, and electrolyte loss. In UC, inflammation usually begins in the colon, then spreads, whereas CD can begin anywhere throughout the tract and can create a skip lesion, or a patchy area of inflammation that skip over some areas. CD can lead to complications, such as strictures and fistulas, and can predispose patients to other diseases, such as arthritis, kidney disease, and gallstones (McDowell et al., 2023
Clinical Manifestations
The clinical manifestations of IBD are weight loss, abdominal pain and bloating, and diarrhea. There may be secondary symptoms present, such as vomiting, fever, redness or pain of the eyes, skin rash, and joint pain. Stress can worsen the symptoms but is not the cause of the disease.
Assessment and Diagnostics
As the nurse performs a physical assessment, tachycardia, fever, anxiety, pallor, and signs of dehydration may be noted. In more serious cases of IBD, anal fistulas, abscesses, or rectal prolapse may be seen. A patient may also have a history of unexplained weight loss, distended painful abdomen, and diarrhea.
An IBD diagnosis will be based on clinical and imaging findings, endoscopic biopsies, and inflammatory laboratory markers. Endoscopy, colonoscopy, or both will allow the practitioner to biopsy tissue and confirm an IBD diagnosis (Table 19.8) (McDowell et al., 2023). Parasitic diseases will also be ruled out. An abdominal x-ray may be performed to rule out bowel obstruction, free air, or toxic megacolon (nonobstructive dilation of the colon that is associated with systemic toxicity).
| Test | Purpose | Nursing Considerations |
|---|---|---|
| Endoscopy | Visualizes the lining of the esophagus, stomach, and small intestines; can be used to collect tissue samples; treat small issues, such as bleeding vessels; clip growths; or remove foreign objects | Monitor the patient after testing for breathing or swallowing difficulty. |
| Colonoscopy | Visualizes the lining of the large intestines, colon, and rectum; can be used to collect tissue samples; treat small issues, such as bleeding vessels; clip growths; or remove foreign objects | Monitor for abdominal cramping and bloating; encourage the patient to pass gas. |
Nursing Care of the Patient with IBD
The nursing care of the patient with IBD will involve ongoing assessments and encouragement of nutrition. Patient education and reassurance about any testing or procedures will be done.
Recognizing Cues and Analyzing Cues
The nurse providing care to a patient with IBD uses both objective and patient-reported data to optimize care. Subjective data may include the patient’s report of acute abdominal pain, bloating, diarrhea, nausea, and vomiting. Vital signs are evaluated, with a focus on blood pressure and heart rate. Physical assessment may reveal abdominal pain on palpation.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Signs of acute infection or bleeding are a high priority. Monitor the patient’s vital signs for an increase in temperature and heart rate, or reduction in blood pressure. Review diagnostic studies and laboratory test results and assist as necessary to prepare the patient for any procedures. Provide patient education about the disease process, diagnostic testing, and treatment plan.
Evaluation of Nursing Care and Outcomes for the Patient with IBD
Symptom improvement and prevention of complications are indications of optimal nursing care. The patient should also have a good understanding of the disease process, treatment plan, and dietary modifications needed to prevent recurrence. The primary patient outcome related to IBD management is symptom improvement. The nurse should evaluate how often symptoms are occurring and note a reduction in the frequency and severity. The patient should also be able to recite information about the disease process and remain compliant with treatment and diet modifications. If these goals are not met, interventions may have to be adjusted.
Medical Therapies and Related Care
Treatment goals are to induce remission of IBD and maintain management of the disease. Drug therapy may be introduced for symptom relief, long-term remission, and to reduce risk of complications. Medications may include
- antibiotics to treat infection
- anti-inflammatory drugs to reduce inflammation
- biologics to neutralize proteins that may be causing inflammation
- immunosuppressant therapy to prevent the body’s immune response from attacking healthy intestinal cells
- pain relievers, such as acetaminophen
- vitamins and supplements to treat any deficiencies
Surgery may be indicated in more severe cases to repair or remove diseased bowel. Dietary recommendations may include avoiding carbonated beverages and high-fiber foods.