Etiology and Pathophysiology

If there is a defect in the muscular wall of the abdomen, the intestine may break through the defect. This protrusion is called a hernia or a rupture.

Hernias are classified as reducible, which means the protruding organ can be returned to its proper place by pressing on the organ, and irreducible or incarcerated, which means that the protruding part of the organ is tightly wedged outside the cavity and cannot be pushed back through the opening. If the protruding part of the organ is not replaced and its blood supply is cut off, the hernia is said to be strangulated. An indirect hernia protrudes through the inguinal ring. A direct hernia protrudes through the posterior inguinal wall.

Signs and Symptoms

If the hernia is not incarcerated, there will just be an abnormal pouching, a “lump” or local swelling out from the abdominal wall or in the groin area (inguinal hernia). When pressure on the abdominal wall is removed by lying down, the swelling disappears. Lifting of heavy objects, coughing, or any activity that puts a strain on the abdominal muscles may force the organ back through the opening, and the swelling reappears.

Some discomfort may accompany the hernia. Pain occurs when the peritoneum becomes irritated or when the hernia is incarcerated or strangulated. The flow of intestinal contents can be blocked by an incarcerated hernia, and cause symptoms of intestinal obstruction. This is an emergency because when the blood supply is restricted, part of the intestine may die.

Treatment

The surgical procedure used in the treatment of a hernia is called a herniorrhaphy, which means a surgical repair of a hernia. The defect is closed with sutures. If the area of weakness is very large, a hernioplasty is done. In this procedure, some type of strong synthetic material is sewn over the defect to reinforce the area. The procedure is now most often done on an outpatient basis.

Careful discharge instructions are given to the hernia patient to prevent respiratory problems because the patient should not cough in the immediate postoperative period. Guidelines on signs and symptoms of complications are sent home with the patient, along with a written list of activities to avoid until healing is complete.

If surgery is not possible because of age or poor surgical risk, the patient may be fitted with an appliance called a truss, which simply reinforces the weakened cavity wall and prevents protrusion of the intestines. The truss is put on in the morning before the patient gets out of bed, because the hernia is more likely to be reduced at that time. It is only a symptomatic measure and does not cure the hernia.

Nursing Management

Pathophysiology

An altered bowel pattern and abdominal pain with bloating are caused by altered motility of the small and large intestines. It is thought that with IBS there is an abnormality of nerve function in the intestine. A chemical mediator, 5-hydroxytryptamine (5-HT) or serotonin, plays a role in bowel motility and visceral sensitivity; 5-HT may be implicated in the pain that occurs with IBS.

Signs and Symptoms

IBS is a group of symptoms that together represent the most common disorder presented by patients who consult gastroenterologists. The three characteristics typical of this disorder are (1) alteration in bowel elimination (either constipation or diarrhea or both); (2) abdominal pain and bloating; and (3) the absence of detectable organic disease. The pattern of bowel dysfunction varies from case to case and each patient seems to have a unique pattern.

Diagnosis

Treatment and Nursing Management

Gas-forming foods such as legumes and those in the cabbage family should be avoided. Avoiding onions, potatoes, cucumbers, coffee, tea, carbonated beverages, and alcohol can be helpful. In some patients, milk is restricted if they have shown evidence of intolerance to it. Lactase tablets may be used, but these may not help if there is sensitivity to dairy products rather than a lactase deficiency. Wearing loose clothing is more comfortable if bloating or increased abdominal pressure occurs. Give instruction about the medications and diet therapy.

Ineffective coping patterns in response to stress may be present in these patients. Randomized, controlled

trials have shown cognitive therapy, psychotherapy, and hypnotherapy help to improve overall symptoms (Harvard Women’s Health Watch, 2009). Consultation with a psychiatric nursing specialist can help the staff nurse develop more realistic goals and effective nursing interventions to improve the patient’s coping skills.

Signs, Symptoms, and Diagnosis

A person with diverticulosis may initially be asymptomatic; however symptoms will develop when inflammation or infection occurs because material has lodged in diverticula. For bowel diverticula, there is usually a history of constipation. There may be rectal bleeding. Diverticulitis of the intestine produces symptoms of diarrhea or constipation, acute severe left lower abdominal pain, fever, and rectal bleeding. The condition may be complicated by intestinal obstruction or by peritonitis if the intestinal wall ruptures. If bleeding is massive, there will be hypotension and dehydration and eventual shock. Computed tomography with contrast is the preferred diagnostic test. Barium enema and colonoscopy should be avoided in acute cases, due to risk of bowel perforation (Carroll, 2009).

Esophageal diverticula produce complaints of dysphagia, regurgitation, nocturnal cough, and halitosis (bad breath). There is a risk of esophageal perforation.

Treatment and Nursing Management

Diverticulosis often can be managed conservatively. A high-fiber diet, increased fluids and bulk laxatives, or stool softeners to control constipation may be all that are needed.

For diverticulitis, antidiarrheal medication may be prescribed. The role of the LPN/LVN is to reinforce education about the diet, fluid intake, and exercise. Mild pain medication may be used for abdominal discomfort in the ambulatory patient. In acute cases of diverticulitis, parenteral antibiotics, nothing-by-mouth (NPO) status for 2 to 3 days and intravenous (IV) fluids may be necessary. Meperidine (Demerol) may be prescribed for pain, rather than morphine, because morphine increases intraluminal pressure (Carroll, 2009). Recurrent episodes of diverticulitis, or perforation and peritonitis, require surgical removal of the affected part of the colon.

Etiology and Pathophysiology

Nonmechanical obstruction results from the absence of peristalsis (movement of contents through the bowel stops). Nonmechanical obstructions may

occur as a result of paralytic ileus (failure of forward movement of bowel contents) following abdominal surgery, from infection, or as a consequence of hypokalemia. Nonmechanical obstructions may be secondary to intestinal thrombus. Infections can occur in some pelvic inflammatory diseases or peritonitis, in uremia, and in heavy-metal poisoning. All of these conditions can interfere with normal peristaltic action and produce a nonmechanical obstruction.

When obstruction occurs, fluid and gas accumulate in the intestine, increasing intraluminal pressure. Peristaltic waves above the obstruction may occur as the intestine attempts to move material down the tract. These waves may cause severe pain.

Signs and Symptoms

The symptoms of intestinal obstruction vary according to the location of the obstruction. Obstructions occurring high in the intestinal tract are characterized by sharp, brief pains in the upper abdomen. Frequent bowel sounds are high pitched above the point of obstruction, and bowel sounds are absent below the obstruction. Other symptoms include vomiting, with rapid dehydration and only slight abdominal distention. An acute intestinal obstruction in the upper abdomen can cause respiratory difficulty because of the pressure of the distended abdomen against the diaphragm.

Obstructions of the colon are characterized by a more gradual onset, with marked abdominal distention as the bowel fills, infrequent vomiting (which occurs late in the process if at all), and pains that last several minutes or longer and correspond to peristaltic waves. Fecal odor or material in the emesis suggests a complete intestinal obstruction.

Diagnosis and Treatment

Nursing Management

Etiology and Pathophysiology

The problem may involve the arterial or the venous blood supply in the form of emboli, thrombosis, or the gradual narrowing and occlusion of vessels. Ischemia can occur as the result of a bowel obstruction or as the result of hypovolemic shock. Underlying cardiac conditions—such as atrial fibrillation or use of vasoconstrictive drugs—can be contributing factors.

Signs, Symptoms, and Diagnosis

A careful history is necessary, because the symptoms are similar to many other abdominal disorders. The sudden onset of severe abdominal pain signals an acute condition. Nausea, vomiting, diarrhea, and abdominal cramps may also be present. The abdomen is tender to palpation and the patient will exhibit guarding. Bowel sounds will be minimal or absent. The white blood cell count is likely to be elevated. Computed tomography angiography is used to confirm the medical diagnosis.

Treatment and Nursing Management

The patient will be NPO and a nasogastric (NG) tube will be inserted to relieve distention. IV hydration is usually ordered, and a Foley catheter may be used to monitor output in the acute phase. If the damage is not severe, conservative measures such as bowel rest and IV hydration will continue. If damage is severe or if the cause is related to an unresolved anatomical obstruction, the patient may require surgery.

Ulcerative Colitis and Crohn’s Disease

Inflammatory bowel disease (IBD) commonly starts between ages 15 and 35. There is a growing tendency to include both ulcerative colitis and Crohn’s disease under the title of IBD. Ulcerative colitis is an inflammation, with formation of ulcers of the mucosa of the colon. It often is a chronic disease and the patient is usually asymptomatic between acute flare-ups. People with ulcerative colitis have a 40% higher incidence of some types of arthritis. Crohn’s disease can involve any part of the GI tract, but most commonly affects the distal ileum and proximal colon.

Etiology

Crohn’s disease and ulcerative colitis have a genetic predisposition. Both disorders also have an ethnic correlation as they are more common among the Jewish population. Immunologic activity is thought to be involved as well because anticolon antibodies are often present in the blood. With ulcerative colitis, infections and emotional tension frequently bring about acute attacks.

Pathophysiology

Signs and Symptoms

The patient with IBD suffers from attacks of diarrhea that may be bloody and contain mucus; abdominal pain with cramping; malaise; fever; and weight loss. The color of blood in the stool depends on the degree and rapidity of the bleed. Slow bleeding and oozing will show a black, tarry stool. If diarrhea is frequent, the blood may be more reddish. The stool color is also dependent on where in the intestine the bleeding is occurring. Blood tends to be redder when the bleeding location is lower in the intestine. The bouts of IBD symptoms often are precipitated by events that cause undue physical or emotional stress. An acute attack can last for days, weeks, or even months, followed by periods of remission extending from a few weeks to several decades. A few patients experience only one attack, and then remain free of symptoms for the rest of their lives. Others have serious intestinal hemorrhage with fluid and electrolyte imbalances.

Diagnosis

Medical diagnosis of IBD usually is based on the patient’s medical history and symptoms. Colonoscopy, flexible sigmoidoscopy, mucosal biopsy, barium enema, and stool analysis may be performed to confirm the diagnosis.

Treatment