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DISTURBANCES IN ELIMINATION

Complications:
INTUSSUSCEPTION
Nursing Interventions:
Definition: Routine pre- and post-op care for abdominal surgery
telescoping of the bowel into itself (usually at the Monitor for fluid and electrolytes and treat for
lower valve) causing edema, obstruction and imbalances
possible necrosis of the bowel Monitor bowel sounds
common about 6 months of age Watch for signs of peritonitis and refer
more common in boys than girls Monitor for signs perforation and shock as evidenced
associated with cystic fibrosis and celiac dse by fever, inc heart rate, changes in level of
consciousness, or blood pressure, and respiratory
Etiology: distress
• Intussusception is idiopathic in 90 percent of
pediatric cases HIRSCHSPRUNG’S DISEASE
Three etiologies: Definition:
1. Intraluminal Is a congenital anomaly
Intraluminal mass is pulled forward by peristalsis Is also known as congenital aganglionosis or
and brings attached bowel wall with it megacolon
2. Intramural Result of an absence of ganglion cells in the rectum
Abnormality of bowel wall (e.g., sessile and upward in the colon
malignancy) causes it not to contract properly,
allowing a kink which serves as a lead point Cause:
3. Extraluminal absence of autonomic parasympathetic ganglion cells
Extraluminal factor (e.g., inflamed appendix) in the rectum and the portion upward in the large
causes area of abnormal peristalsis, allowing a colon
kink which serves as a lead point result in mechanical obstruction from the inadequate
motility in the distal segment
Incidence:
In children Signs and Symptoms:
Over 90% have no pathologic lead point failure or daily in passing meconium
Most thought due to lymphoid hypertrophy abdominal distension temporarily relief by rectal exam
following viral infection loose stool: ribbon-like stool
Less than 10% due to diverticulum, polyp, nausea, anorexia and lethargy
lymphoma bile stained or fecal vomiting
In adults loss weight or failure to grow
Over 90% have a demonstrable cause
60% due to neoplasm (60% malignant, 40% Diagnostic Exam:
benign) Rectal biopsy to confirm presence or absence of
30% due to non-neoplastic abnormalities, such ganglion cells
as inflammation, trauma or suture lines
10% are idiopathic Management:
drug therapy
Epidemiology: isotonic enemas
In developed nations diet therapy
Majority are in children surgery:
Peak incidence 5-9 months of age palliative- loop or double bowel colostomy
Approximately 10% occur in adults corrective- abdomino-perineal pull-through
Seen in all age groups bowel containing ganglia is pulled down and
Approximately equal in males and females anastomosed to the rectum
·
Signs and Symptoms: Nursing Interventions:
severe colicky abdominal pain administer enemas as ordered
piercing cry and child draws knees to abdomen mineral oil or isotonic saline
vomiting of bile-stained fecal material or gastric do not use tap water or soap suds enema in
contents infants because of danger of water
currant jelly-like stools intoxication
tender and distended abdomen use volume appropriate to weight of child
palpable sausage-shaped mass in the RUQ do not treat loose stools; child is constipated
hypoactive or hyperactive bowel sounds administer TPN
tender and distended abdomen provide low residue diet
palpable sausage-shaped mass in the RUQ client teaching and discharge planning concerning
hypoactive or hyperactive bowel sounds colostomy care and decrease residue

Diagnostic Test: VOLVULUS


- Barium enema Definition:
A volvulus is a bowel obstruction in which a loop of
Management (Barium Enema): bowel has abnormally twisted on itself.
Barium enema
Antibiotic, IV fluids General Considerations:
NGT to decompress GIT
Surgery - Twisting of loop of intestine around its mesenteric
attachment site may occur at various sites in the
Surgical consultation: GI tract
Colonic: surgical resection without reduction because - Most commonly
of risk of venous embolization of tumor or - Rarely: stomach, small intestine, transverse
seeding from a malignant tumor colon
- Results in partial or complete obstruction
Enteroenteric: depends on cause and symptoms; may - May also compromise bowel circulation
require resection or manual reduction during resulting in ischemia
surgery, may be treated with enema reduction, - Sigmoid volvulus most common form of GI
or may require no intervention tract volvulus
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- Accounts for up to 8% of all intestinal Hernias can be classified according to their
obstructions anatomical location:
- Most common in elderly persons Inguinal hernia
- Patients almost always have a history of A. Indirect
chronic constipation - A congenital in origin due to the presence of
procesus vaginalis
Predisposing Factors: - Herniation thru the spermatic cord then to the
Chronic constipation inguinal canal
High-roughage diet - Common than direct hernia
Roundworm infestation - Common in children and young adult
Megacolon - More common in male than female
20-25% mortality rate - Common in right side
Peak age > 50 yrs. B. Direct
Second largest group à children - Weakness of the muscle of the abdominal wall
Torsion usually counterclockwise ranging from 180 – - Common on elderly men than women
540 degrees Ventral
Luminal obstruction generally @ 180degrees Incisional hernia
Venous occlusion generally @ 360 degrees à Occurs at the site of previous surgical incision that
gangrene & perforation healed inadequately
Risk factor: Infection, inadequate nutrition, distension,
Causes: obesity
- congenital intestinal malrotation.- Midgut Femoral
volvulus Hernia occur thru the femoral ring
- abnormal intestinal contents or adhesions.- More common in female
Segmental volvulus High incidence of strangulation and incarceration
- minor predisposing factors such as redundant Umbilical
(excess, inadequately supported) intestinal Due to increased abdominal pressure
tissue and constipation.- Volvulus of the More common in female
cecum, transverse colon, or sigmoid colon Usually occurs in obese and multiparous women
complete or incomplete: completely or partially
Presentation: herniated
Regardless of cause, volvulus causes symptoms by internal or external:
two mechanisms. irreducible
• One is bowel obstruction, manifested as Strangulation: necrosis and gangrene, which may
abdominal distension and vomiting. become fatal.
• The other is ischemia (loss of blood flow) to Causes:
the affected portion of intestine Predisposing factors
• heavy lifting.
Signs and Symptoms: • Family history of hernias
– May present as abdominal emergency • Undescended testicles
• Acute distension • Extra weight
• Colicky pain • Chronic cough
• Failure to pass flatus or stool (constipation is • Chronic constipation, straining to have bowel
prevailing feature) movements
• Vomiting is late sign • Enlarged prostate, straining to urinate
– Distention may compromise respiratory & • stretching of muscles during pregnancy,
cardiac function • scars from previous surgery.
– May also present with surprisingly few signs and
symptoms in bedridden and debilitated Clinical Manifestations:
• Physical examination  Hernias may present either with pain at the
– Abdominal distention site
– +/- palpable mass  a visible or palpable lump,
 vague symptoms resulting from pressure on
Diagnostics: an organ which has become "stuck"
• Abdominal plain films usually diagnostic sometimes leading to organ dysfunction.
– Inverted U-shaped appearance of  Fatty tissue usually enters a hernia first, but
distended sigmoid loop it may be followed by or accompanied by an
• UPPER GI SERIES organ
– Bird’s-beak or bird-of-prey sign à
seen on barium enema as it MANAGEMENT: SURGICAL
encounters the volvulated loop Most abdominal hernias can be surgically repaired,
and recovery rarely requires long-term changes
• CT scan useful in assessing mural wall in lifestyle.
ischemia Uncomplicated hernias are principally repaired by
pushing back, or "reducing", the herniated
Treatment: tissue, and then mending the weakness in
• Laparoscopic de-rotation or bowel resection muscle tissue
• De-rotation & decompression by barium When to Contact a Medical Professional
enema or with rectal tube, colonoscope, or If a hernia and the contents cannot be pushed back
sigmoidoscope if no signs of bowel ischemia into the abdomen using gentle pressure
or perforation If develop nausea, vomiting, or a fever with hernia
• Cecopexy à suture fixation of bowel to The hernia becomes red, purple, dark, or discolored
parietal peritoneum may prevent recurrence You have groin pain, swelling, or a bulge
HERNIA An umbilical hernia fails to heal on its own by the time
Definition: your child is 5 years old
A hernia is a protrusion of a tissue, structure, or part
of an organ through the muscle tissue or the Nursing Interventions:
membrane by which it is normallycontained. Post-op:
V/S monitoring
Characteristics: Wound care

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Hydration IMPERFORATED ANUS
Advance diet DESCRIPTION:
Administer analgesic and antibiotic An imperforate anus is a defect that occurs during the
fifth to seventh weeks of fetal development.
Incidence:
Diverticulitis and Diverticulosis Imperforate anus affects 1 in 5,000 babies and is
Diverticulosis – is an outpouching or Herniation of slightly more common in males.
the intestinal mucosa
Non-inflamed diverticuila TYPES
Can occur in any part of the intestine but most low imperforte anus where the rectum may be in the
common in the sigmoid colon normal location but is too tight to allow the infant
Divericulitis – is an inflammation of one or more to have a bowel movement
diverticula that results a diverticula that results intermediate imperforate anus where the opening is
when a diverticula perforates too close to the urethra
Etiology / risk factor: high imperforate anus where the rectal opening is
Low fiber diet completely absent.
Muscle weakness of the bowel
Diverticulitis: DIAGNOSTIC TEST
- Undigested foods block the diverticula-invasion by thorough physical examination that includes seeing if
bacteria the anus is open and in the proper position.
Incidence: Abdominal X-rays -- These provide a general
Common in men and women above 45 yo overview of the anatomical location of the
Obese imperforate anus in a cross-table lateral view
1/3 in population over 50 yo
Pathophysiology: CLINICAL MANIFESTATION:
Diverticula has narrow neck line that communicates • Failure to pass stool within 1st 24 hours
with the bowel lumen • Abdominal distention
Weak points in the musculature exist where the • Presence of stool in the urine
branches of the blood vessels penetrates the • Nausea and vomiting
bowel wall
Weak points create bowels to protrude MANAGEMENT: SURGICAL
Common in sigmoids because of high pressure to • A low imperforate anus is repaired with an
move the stool into the rectum anoplasty.
When fecaliths do not liquify and drain in the – This is an operative procedure done
diverticula – will lead to inflammation to move the fistula opening back to
When become congested will lead to bleeding or the anal sphincter.
perforation
Chronic diverticulis occurs as a result of scarring, then • Colostomy- usually done within the first day
narrowing of the bowel lumen finally to obstruction of life.
Signs and Symptoms: – A colostomy is a surgically created
Left lower quadrant pain w/c increases with coughing, intestinal opening on the abdominal
straining, or lifting wall. This allows the infant to have
Diarrhea, constipation normal bowel movements and
Elevated temperature relieves the bowel obstruction.
Nausea and vomiting
Abdominal distension and tenderness NURSING MANAGEMENT:
Palpable tender rectal mass PREOPERATIVE:
Blood in the stool in 15% of cases General consideration:
Change in bowel pattern, and character • Pacifier to meet sucking needs, NGT for
Fever, abdominal pain and urinary manifestation decompression
Medical mgt: • Maintain IV and maintain I and O
Diet therapy if asymptomatic • Meet Emotional needs; consistent parenting,
High fever diet, bulk laxative touching, pacifier
NPO
NGT feeding Improving breathing Pattern
IV fluids, antibiotics • Monitory respiratory embarrassment that
Report to the physician may result from abdominal distention
Surgical mgt: • Administer oxygen as ordered
Indication: hemorrhage, obstruction, abscess and • Elevate head and chest of the infant by tilting
perforation the matress
Ligation and removal of the sac
Resection of the vowel involved Relieving pain
Temporary colostomy 1. Note degree of abdominal tenderness
Nursing intervention: 2. Take sequential measurement of abdominal
Maintain on NPO status girth
Administer fluids and electrolytes IV or total parenteral 3. 3. NGT to low intermittent suction to relieve
nutrition abdominal distention and vomiting
Restrict the clients activity
Monitor bowel sounds and for abdominal tenderness NURSING MANAGEMENT:
and crampness Provide adequate Nutrition
Monitor stools NPO or TPN as ordered
Monitor for perforation, peritonitis and hemorrhage Monitor Iv fluids
Instruct the client to consume a low residue, high Post operative:
protein diet A. General Consideration
Avoid gas forming foods and milk products • Monitor respiratory status, IV, electrolytes,
Avoid smoking I & O, bowel sounds
Administer bulk forming agents Maintain Hydration status
Administer antimicrobial agents, corticosteroids and • -Offer oral fluids as soon as peristalsis is
immunosuppressants to prevent infection and back or as ordered
reduce inflammation.
NURSING MANAGEMENT:
• Keep incision site clean and dry
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• Assess for correct colostomy functioning 4. administer stool softeners
-Proximal loop empties stools 5. Recognition and reporting immediately to physician
-Distal loop empties mucus of the following signs and symptoms:
• Provide colostomy care 1. Rectal bleeding
• Provide psychological support 2. Continued pain on defecation
3. Pus – like drainage from rectal area
NURSING MANAGEMENT: 6. Provide client teaching and discharge planning
Prevent complications concerning
Monitor Vital signs a. Dietary modification (low-residue, soft diet,
Monitor proper functioning of colostomy progress to high fiber/fresh fruits, force fluids 2.5-
Note drainage of colostomy 3L/day)
Note abdominal distention b. Defecate when urge is felt
Change wound dressing daily c. Use of stool softeners as needed until
Frequent hand washing healing occurs.
d. Sitz baths after each bowel movement.
e. Perineal care with antiseptic solutions.
HEMORRHOIDS

GENERAL INFORMATION:
Congestion and dilation of the veins of the rectum and
anus
Usually result from impairment of flow of blood
through the venous plexus.
Most commonly occur between ages 20-50.
Predisposing conditions:
Occupations requiring long periods of standing
increased intra-abdominal pressure
prolonged constipation
Pregnancy
heavy lifting
Obesity
straining at defecation
portal hypertension.

TYPES
• Internal hemorrhoids
• External hemorrhois
• Thrombosed hemorrhoids

ASSESSMENT FINDINGS:
1. Bleeding with defecation, hard stools with
streaks of blood.
2. Pain with defecation, sitting, or walking.
3. Protrusion of external hemorrhoids upon
inspection.

Diagnostic Tests:
• DRE
• Proctoscopy reveals presence of internal
hemorrhoids
• Hgb and Hct decreased if bleeding is
excessive and/or prolonged.

MEDICAL MANAGEMENT:
1. Stool softeners, local anesthetics, or anti-
inflammatory creams.
2. Diet modification: high fiber, adequate liquids.

Surgery

Hemorrhoidectomy: surgical excision of hemorrhoids


indicated when there is prolapse, severe pain, and
excessive bleeding.
- Rubber band ligation
-Cryosurgery

PRE op:
Prepare the client for hemorrhoidectomy.
• provide laxatives/enemas to promote
cleansing of the bowel.
• Low residue diet to reduce the bulk of the
stool

POSTOPERATIVE NURSING INTERVENTIONS:


1. Provide routine post-op care.
2. Assess for rectal bleeding; inspect rectal
area/dressings every 2-3hours and report significant
increases in bloody drainage.
3. Promote comfort.
a. Assist client to side-lying or prone position
b. provide flotation pad when sitting.
c. Administer analgesics as ordered
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