ADULT MEDICAL-SURGICAL NURSING

Digestive Disorders

Comprehensive Clinical Guide to Gastrointestinal Conditions

4 Major Conditions
10-30 Typical Age Range
#1 Acute Abdomen Cause
FOUNDATIONAL CONCEPT

Dysphagia

DEFINITION

Dysphagia: Difficulty swallowing. This can occur due to structural damage to the esophageal lining or neurological impairments affecting the swallowing mechanism.

Etiology

Structural Causes

  • Scar tissue: From previous intubation or trauma
  • Muscle atrophy: Weakening of pharyngeal/esophageal muscles
  • Damage to soft palate lining: From surgery, radiation, or injury
  • Esophageal strictures: Narrowing from GERD or other causes
  • Tumors or masses: Obstructing the swallowing pathway

Neurological Causes

  • Multiple sclerosis: Demyelination affecting cranial nerves
  • Guillain-Barré syndrome: Myelin sheath attack
  • Stroke: Damage to swallowing centers in brain
  • Parkinson's disease: Dopamine imbalance affecting muscle coordination
  • Neurotransmitter imbalances: Particularly dopamine-related disorders
NEURONAL FUNCTION REVIEW

Understanding the Nervous System Impact on Swallowing

Neurons transmit messages throughout the body via electrical and chemical signals. When this system is damaged, dysphagia can result:

  • Dendrites: Receive incoming messages from other neurons
  • Axon body: Cell body that processes information like a computer
  • Axon: Long tail-like structure that transmits signals away from cell body
  • Myelin sheath: Fatty insulation around the axon that speeds signal transmission (think of it as "bubble wrap" protection)

Key Point: When the myelin sheath is damaged (as in Multiple Sclerosis or Guillain-Barré syndrome), messages can be lost or distorted, leading to dysphagia and other neurological symptoms.

Nursing Care for Dysphagia

ASPIRATION PNEUMONIA: The most serious complication of dysphagia. All nursing interventions focus on preventing aspiration while maintaining adequate nutrition. This is the BIGGEST thing to watch for in clients with dysphagia.

Key Interventions

  1. Keep Head of Bed Elevated
    • HOB at 30-45 degrees during meals and for 30-60 minutes after eating
    • Upright positioning uses gravity to assist swallowing
    • Significantly reduces risk of aspiration
  2. Thicken Liquids
    • Thin liquids are hardest to control and most likely to be aspirated
    • Commercial thickeners available in different consistencies: nectar-thick, honey-thick, pudding-thick
    • Critical: Thickness level must be determined by swallow study results
    • Patient can progress off thickened liquids as swallowing improves
    • Never make assumptions about thickness needed - always follow swallow study recommendations
  3. Swallow Study (Modified Barium Swallow)
    • Fluoroscopic examination to visualize the swallowing mechanism in real-time
    • Determines safe food and liquid consistencies for each individual patient
    • Identifies specific swallowing abnormalities and aspiration risk
    • Essential: This study is required for establishing proper diet orders
    • Recommend and ensure completion if not already done
  4. Modify Food Texture
    • Progress from pureed → soft/mechanical soft → regular diet as tolerated and per swallow study
    • Avoid: Small seeds, nuts, dry/crumbly foods that can easily be aspirated
    • Example of contraindicated foods: Yogurt with sunflower seeds (seeds are high in fiber and healthy, but dangerous for dysphagia patients)
    • Foods should be moist and easily formed into a bolus
    • Consider texture and how easily food breaks apart in the mouth
  5. Interdisciplinary Team Approach
    • Speech-Language Pathologist (SLP): Conducts swallowing assessments, provides swallowing exercises and strategies
    • Occupational Therapy (OT): Often the FORGOTTEN resource! OT provides adaptive equipment, optimal positioning techniques, and helps patients achieve their "new normal" while maintaining independence with ADLs
    • Dietitian: Ensures nutritional adequacy and creates individualized meal plans
    • Nursing: Implements plan, monitors for complications, educates patient and family
Occupational Therapy (OT) - The Often Forgotten Resource: While speech therapy and dietary consultations are commonly remembered for dysphagia patients, OT is frequently overlooked. OT helps patients integrate all therapeutic interventions into daily life, providing strategies to make eating safer and easier. They look at the whole picture: How can we make this easier for the patient? How do we fit PT, ST, and dietary recommendations together so patients can successfully complete their ADLs?

Assessment Priorities

Before Meals

  • Level of alertness
  • Ability to follow commands
  • Gag reflex present
  • Positioning adequate

During Meals

  • Coughing or choking
  • Wet, gurgly voice quality
  • Pocketing food in cheeks
  • Time to complete meal

After Meals

  • Respiratory status
  • Temperature monitoring
  • Signs of aspiration
  • Mouth care completed

Ongoing Monitoring

  • Weight trends
  • Hydration status
  • Nutritional markers
  • Lung sounds
UPPER GI DISORDERS

Gastritis

PATHOPHYSIOLOGY

Gastritis: Inflammation of the stomach lining (mucosa). The healthy mucosa and normal flora become inflamed and irritated, leading to symptoms and potential complications.

Etiology

H. PYLORI - CRITICAL INFORMATION

Helicobacter pylori (H. pylori): This bacteria is one of the main causes of peptic ulcer disease and can be attributed to colorectal cancer development.

Mechanism: H. pylori inflames and creates damage in the lining of the stomach. This leads to a dangerous progression:

Prolonged Inflammation → Dysplasia → Cancer

Think of it like recurrent sunburns: If you get sunburns over and over again, your cells have to adapt. They die off quicker and are replaced with immature cells. Eventually, these dysplastic cells can grow into cancerous cells. The same process happens inside the digestive tract.

Clinical Manifestations

Changes in Bowel Habits: For any client with GI complaints, one of the first questions to ask is about changes in bowel habits. When did it start? What makes it better? What makes it worse? This helps differentiate between various conditions like celiac disease, lactose intolerance, IBS, Crohn's disease, or ulcerative colitis.

Diagnostics

STOOL GUAIAC TEST

Recognition essential for exams! The stool guaiac test (also called fecal occult blood test) checks for blood in stool that cannot be seen with the naked eye.

How it's done: Patient provides stool sample, it's smeared on a card, and sent to lab for analysis.

Why it matters: Catches occult blood loss early, allowing intervention before patient becomes significantly anemic.

Medical Management

Medications

Dietary Management

BLAND DIET for Gastritis:
  • Mashed potatoes with NO seasoning
  • Baked or boiled chicken with NO seasoning
  • Low sodium chicken broth
  • Jell-O and popsicles (AVOID RED if bleeding suspected)

CRITICAL: NO RED FOODS/DRINKS if GI bleeding suspected!

  • No red popsicles (hospitals don't even order them)
  • No red Jell-O
  • No red Gatorade
  • Reason: Cannot distinguish between blood and red food coloring

NO COFFEE - irritates stomach lining

Stress Reduction - CRITICAL Component

Your job is to protect the client!
  • Provide quiet time for patient - lights out, minimize noise
  • Family management: If visitors are stressing patient out, educate them on stress reduction
  • Give family members a voucher to cafeteria if needed - get them out of the room!
  • If family continues to stress patient and you see no behavior change, get your charge nurse and provider involved
  • Sometimes family is frustrated about other issues and taking it out on the situation - listen and try to resolve their concerns
  • Educate them: "We're trying to provide quiet time. I can monitor patient from the desk. The device will alert me if anything is wrong."
  • If unsure how to handle difficult family situations, get a seasoned nurse to help

Peptic Ulcer Disease (PUD)

Etiology - NSAID Use

TAKING NSAIDs PROPERLY - THE "MEDICATION SANDWICH"

Critical Patient Education: Taking NSAIDs on an empty stomach or crushing them increases gastritis and ulcer risk!

Why crushing aspirin is dangerous: The coating on aspirin is there to protect your stomach lining. When you crush it, you destroy that protection.

The "Medication Sandwich" Method:

  1. Chew and swallow several bites of food FIRST
  2. Take the medication in the MIDDLE
  3. Eat more food AFTERWARD
  4. Drink PLENTY of fluids throughout

Remember: Your stomach can't do its job with only half a cup of water all day!

Types of Peptic Ulcers - KEY DIFFERENCES

Duodenal Ulcers

  • Location: Beginning of duodenum
  • Pain pattern: Pain RELIEVED by eating food
  • Why: Food stimulates more mucus and surfactant production, which coats the area and makes it feel better

Gastric Ulcers

  • Location: Stomach lining
  • Pain pattern: Pain WORSENED by eating food
  • Why: Food and acid directly touch the stomach ulcer, causing immediate pain
When a patient has BOTH types: They're confused and miserable! Do I eat or not? When I eat, I'm in pain. The discomfort is constant and confusing for the patient.

Common Symptoms

Diagnostics

Treatment

ACUTE ABDOMINAL EMERGENCY

Appendicitis

PATHOPHYSIOLOGY

Appendicitis: Inflammation of the appendix, a small wormlike structure attached to the cecum. The appendix fills with digestive byproducts and empties into the cecum but is prone to obstruction and subsequent infection.

Epidemiology and Risk Factors

Clinical Presentation

CLASSIC SYMPTOM PROGRESSION
  1. Periumbilical Pain

    Dull, diffuse pain begins around the umbilicus as the appendix becomes inflamed

  2. Migration to Right Lower Quadrant

    Pain becomes sharp and localized to McBurney's point (⅓ distance from anterior superior iliac spine to umbilicus) as inflammation involves the peritoneum

  3. Systemic Symptoms

    Anorexia, nausea, and low-grade fever accompany the pain

⚠️ CRITICAL NURSING POINT - REBOUND TENDERNESS ASSESSMENT ⚠️

ASSESS REBOUND TENDERNESS ONCE ONLY. DO NOT REPEATEDLY ASSESS.

  • Repeated assessment of rebound tenderness can cause the appendix to RUPTURE
  • Trust handoff report: If the previous nurse documented rebound tenderness, DO NOT check again
  • This is a common mistake that new nurses make - they feel they need to assess everything themselves
  • Use clinical judgment and common sense: If peritonitis is suspected, don't keep poking the abdomen!

After rupture sequence:

  1. Patient experiences brief pain relief (2-3 minutes) - "This feels so much better!"
  2. Then experiences the WORST PAIN OF THEIR LIFE as peritonitis develops

Your responsibility: Do not be the reason the appendix ruptured. Assess once if needed for initial evaluation, then rely on documented findings.

Physical Examination Findings

McBurney's Point Tenderness

Direct tenderness at the classic anatomical location in the right lower quadrant (⅓ distance from anterior superior iliac spine to umbilicus)

Rebound Tenderness

Pain worsens when pressure is suddenly released from the abdomen (indicates peritoneal irritation)

Rovsing's Sign

Palpation of the left lower quadrant causes pain in the right lower quadrant (referred peritoneal irritation)

Ruptured Appendix Complications: If appendicitis progresses to rupture, peritonitis develops with abdominal distention, severe pain, fever, and overall worsening of the patient's condition. This is a surgical emergency requiring immediate intervention.

Diagnostic Evaluation

Diagnostic Test Expected Findings Purpose
WBC Count Elevated (>10,500/mm³) Confirms inflammatory process
Neutrophil Percentage >75% of WBCs Indicates acute bacterial infection
C-Reactive Protein Elevated within first 12 hours Inflammatory marker
CT Scan or Ultrasound Visualizes inflamed appendix Confirms diagnosis definitively
Pregnancy Test Negative Rules out ectopic pregnancy in females
Urinalysis Normal Rules out UTI or renal calculi

Treatment: Appendectomy

SURGICAL INTERVENTION

Immediate surgery is required to prevent complications such as rupture and peritonitis. Laparoscopic appendectomy is the preferred approach due to smaller incisions, less pain, and faster recovery.

Pre-Operative Nursing Management

DO NOT administer enemas in suspected appendicitis. This can increase intraluminal pressure and precipitate rupture of an inflamed appendix.

Post-Operative Nursing Management

  1. Position Patient Upright
    • Semi-Fowler's or high-Fowler's position
    • Facilitates drainage and reduces tension on the incision
    • Improves respiratory effort and comfort
  2. Monitor Bowel Function
    • Assess for return of bowel sounds in all four quadrants
    • Indicates resolution of postoperative ileus
    • Patient may advance diet as tolerated once bowel sounds present
  3. Monitor Urine Output
    • Goal: At least 30 mL/hour or 0.5 mL/kg/hr
    • Ensures adequate perfusion and hydration
    • Alert physician if output falls below expected
  4. Promote Early Ambulation
    • Begin ambulation on postoperative day 1 if possible
    • Administer pain relief prior to ambulation
    • Reduces risk of complications (pneumonia, DVT, ileus)
    • Promotes return of bowel function

Nursing Goals and Expected Outcomes

PRIORITY NURSING DIAGNOSES
  • Acute Pain related to inflammation and surgical incision
  • Risk for Deficient Fluid Volume related to NPO status and fluid loss
  • Anxiety related to acute illness and surgical intervention
  • Risk for Infection related to ruptured appendix or surgical site
  • Impaired Skin Integrity related to surgical incision
  • Imbalanced Nutrition: Less Than Body Requirements related to NPO status and anorexia

Patient Education

Peritonitis Risk: Inflammation of the abdominal lining (peritoneum) is the most serious complication of appendicitis. It occurs when the appendix ruptures, spilling bacteria and infected material into the peritoneal cavity. Signs include rigid, board-like abdomen, severe pain, fever, and hemodynamic instability.
INFLAMMATORY BOWEL DISEASE

Crohn's Disease

PATHOPHYSIOLOGY

Crohn's Disease: A chronic inflammatory bowel disease (IBD) characterized by transmural inflammation that can affect any portion of the gastrointestinal tract from mouth to anus. Unlike ulcerative colitis, Crohn's involves all layers of the bowel wall and often presents with "skip lesions" - areas of diseased bowel separated by healthy tissue.

Epidemiology and Risk Factors

Risk Factors and Triggers

Genetic Factors

NOD2/CARD15 gene mutations, family history, ethnicity

Environmental

Smoking (doubles risk), NSAIDs, stress, diet high in refined foods

Immunologic

Abnormal immune response to intestinal bacteria

Microbiome

Altered gut bacteria composition, reduced diversity

Clinical Presentation

CLASSIC TRIAD
  1. Abdominal Pain

    Cramping pain, often in right lower quadrant (terminal ileum involvement). Pain typically occurs after meals and may be relieved by defecation.

  2. Chronic Diarrhea

    3-20 loose stools daily, may contain blood or mucus. Nocturnal diarrhea common. Fat malabsorption leads to steatorrhea (fatty, foul-smelling stools).

  3. Weight Loss

    Due to malabsorption, reduced oral intake (fear of pain), and increased metabolic demands from chronic inflammation.

Systemic Manifestations

Extraintestinal Manifestations (25-40% of patients)

Common

  • Arthritis/arthralgia (25%)
  • Aphthous stomatitis (mouth ulcers)
  • Erythema nodosum (tender red nodules)
  • Episcleritis/uveitis (eye inflammation)

Less Common

  • Pyoderma gangrenosum (skin ulcers)
  • Primary sclerosing cholangitis
  • Ankylosing spondylitis
  • Osteoporosis

Complications

Major Complications: Crohn's disease can lead to serious complications requiring surgical intervention:
  • Strictures: Bowel narrowing from chronic inflammation and scarring → obstruction
  • Fistulas: Abnormal connections between bowel and other organs (30-40% of patients)
  • Abscesses: Localized infections requiring drainage
  • Perforation: Medical emergency requiring immediate surgery
  • Toxic megacolon: Life-threatening colonic dilation

Diagnostic Evaluation

Diagnostic Test Expected Findings Purpose
Colonoscopy with Biopsy Skip lesions, cobblestone appearance, deep ulcers, strictures Gold standard for diagnosis; assess disease extent and obtain tissue
Upper Endoscopy Aphthous ulcers, inflammation in upper GI tract Evaluate upper GI involvement (30% of patients)
CT/MR Enterography Bowel wall thickening, mesenteric fat stranding, fistulas, abscesses Assess small bowel involvement and complications
CBC Anemia, leukocytosis, thrombocytosis Assess disease activity and complications
CRP/ESR Elevated during active disease Monitor inflammation and treatment response
Fecal Calprotectin Elevated (>250 μg/g suggests active IBD) Noninvasive marker of intestinal inflammation
Vitamin B12, Folate, Iron Studies Deficiencies common, especially with ileal disease Assess nutritional status and malabsorption
Crohn's vs Ulcerative Colitis: Key differences include: Crohn's can affect any part of GI tract (UC limited to colon), transmural inflammation (UC limited to mucosa), skip lesions present (UC has continuous involvement), and smoking worsens Crohn's but may protect against UC.

Medical Management

Treatment Goals

Step-Up Therapy Approach

  1. Aminosalicylates (5-ASA)
    • Medications: Mesalamine (Asacol, Pentasa), Sulfasalazine
    • Use: Mild disease, primarily colonic involvement
    • Nursing considerations: Monitor for allergic reactions, headaches, GI upset
  2. Corticosteroids
    • Medications: Prednisone, Budesonide (Entocort)
    • Use: Moderate to severe flares, NOT for maintenance
    • Nursing considerations:
      • Monitor blood glucose, blood pressure, signs of infection
      • Assess for mood changes, insomnia
      • Calcium/Vitamin D supplementation for bone protection
      • Taper slowly to prevent adrenal insufficiency
  3. Immunomodulators
    • Medications: Azathioprine (Imuran), 6-mercaptopurine (6-MP), Methotrexate
    • Use: Steroid-sparing maintenance therapy
    • Nursing considerations:
      • Takes 3-6 months for full effect
      • Monitor CBC, liver function tests regularly
      • Screen for TPMT enzyme deficiency before starting
      • Counsel about infection risk, avoid live vaccines
  4. Biologic Therapy
    • Anti-TNF agents: Infliximab (Remicade), Adalimumab (Humira), Certolizumab (Cimzia)
    • Integrin inhibitors: Vedolizumab (Entyvio)
    • IL-12/23 inhibitor: Ustekinumab (Stelara)
    • Use: Moderate to severe disease, fistulizing disease
    • Nursing considerations:
      • Screen for TB, hepatitis B/C, HIV before starting
      • Monitor for infusion reactions
      • Increased infection risk - educate about signs/symptoms
      • No live vaccines while on therapy
MEDICATION ALERT

Infliximab (Remicade) Infusion Protocol:

  • Premedicate with antihistamine and acetaminophen to prevent reactions
  • Infuse over 2+ hours with vital sign monitoring
  • Have emergency medications available (epinephrine, steroids)
  • Monitor for acute reactions: fever, chills, chest pain, dyspnea, rash
  • Delayed reactions possible 3-12 days post-infusion

Nutritional Management

NUTRITIONAL PRIORITIES
  • Correct deficiencies: Iron, B12, folate, vitamin D, zinc
  • Maintain adequate calories and protein for healing
  • Small, frequent meals better tolerated than large meals
  • Elemental or polymeric formulas for severe disease or bowel rest
  • Consider exclusive enteral nutrition (EEN) in pediatric patients

Dietary Modifications During Flares

Surgical Management

Surgery Statistics: 70-80% of Crohn's patients will require surgery within 20 years of diagnosis. Surgery is not curative - disease recurrence is common, with 50% requiring additional surgery within 10 years.

Indications for Surgery

Surgical Procedures

Nursing Management

PRIORITY NURSING INTERVENTIONS
  1. Pain Assessment and Management
    • Use numeric pain scale to track severity
    • Note relationship to meals and bowel movements
    • Avoid NSAIDs (can worsen disease)
    • Use acetaminophen, antispasmodics, or opioids as ordered
  2. Monitor Nutritional Status
    • Daily weights during hospitalization
    • Intake and output documentation
    • Monitor albumin, prealbumin, transferrin
    • Assess for signs of specific deficiencies
  3. Skin and Perianal Care
    • Assess perianal area for fissures, fistulas, abscesses
    • Provide meticulous skin care with frequent diarrhea
    • Use barrier creams to protect skin
    • Sitz baths for perianal discomfort
  4. Medication Administration and Monitoring
    • Ensure proper timing of medications with meals
    • Monitor for adverse effects of immunosuppressants
    • Educate about adherence importance
    • Track laboratory values per protocol
  5. Psychosocial Support
    • Assess coping mechanisms and support systems
    • Screen for depression and anxiety (common comorbidities)
    • Refer to IBD support groups
    • Provide education about disease chronicity

Patient Education

TEACHING PRIORITIES
  • Disease process: Chronic nature, remission/flare pattern
  • Medication adherence: Even during remission
  • Infection prevention: Hand hygiene, avoid sick contacts, vaccination schedule
  • When to seek care:
    • Severe abdominal pain or distention
    • High fever (>101°F/38.3°C)
    • Persistent vomiting
    • Signs of dehydration
    • Blood in stool increasing
  • Lifestyle modifications:
    • Smoking cessation (critical - worsens disease)
    • Stress management techniques
    • Regular exercise as tolerated
    • Importance of regular follow-up
Quality of Life Focus: Crohn's disease significantly impacts patients' lives - from dietary restrictions to medication side effects to surgery fears. Emphasize that while Crohn's is chronic and incurable, most patients can achieve good quality of life with proper management. Remission is possible, and many patients lead full, active lives between flares.

Pregnancy Considerations

Monitoring and Follow-Up

Monitoring Parameter Frequency Rationale
CBC Every 3-6 months or more if on immunosuppressants Monitor for anemia, leukopenia from medications
CRP/ESR With flares and to assess treatment response Objective measure of inflammation
Liver enzymes Every 3 months if on methotrexate or azathioprine Monitor for hepatotoxicity
Vitamin B12 Annually if ileal disease or resection Malabsorption common with ileal involvement
Bone density (DEXA) Baseline and every 2 years if on steroids Increased osteoporosis risk
Colonoscopy 8 years after diagnosis, then every 1-3 years Colorectal cancer surveillance
FUNCTIONAL GI DISORDER

Irritable Bowel Syndrome (IBS)

PATHOPHYSIOLOGY

Irritable Bowel Syndrome (IBS): A chronic functional gastrointestinal disorder characterized by abdominal pain and altered bowel habits without identifiable organic pathology. No inflammation or tissue damage is found in the intestines during diagnostic workup.

Epidemiology and Etiology

Factors That Worsen Symptoms

Stress

Psychological stress directly affects gut motility and sensitivity

Hormones

Menstrual cycle can trigger or worsen symptoms in women

Infections

Post-infectious IBS can develop after gastroenteritis

Food Intolerance

Certain foods trigger symptoms without true allergy

Clinical Presentation

IBS SUBTYPES
  • IBS-D: Irritable Bowel Syndrome with predominant Diarrhea
  • IBS-C: Irritable Bowel Syndrome with predominant Constipation
  • IBS-M: Mixed pattern with both constipation and diarrhea
STRESS - THE PRIMARY TRIGGER

Stress is the MAIN trigger for IBS symptoms. Understanding the nervous system's role is critical:

  • Examples: Have you ever had to go to the bathroom right before an exam? Or before a big game? This is IBS in action!
  • Sympathetic System (Fight or Flight): When activated by stress, SHUTS DOWN the GI tract
  • Parasympathetic System: When stress resolves and you rest, this system says "EVACUATE!" - and then you have urgent bowel movements
  • This explains why symptoms worsen with stress and why many young adults and students experience IBS

Risk Factors

Clinical Presentation

Tenesmus: The urgency to defecate but nothing is there. This occurs because the bowel is inflamed and sends false signals. Always ask patients about this symptom!

Characteristic Symptoms

CRITICAL ASSESSMENT QUESTION

ALWAYS ask about changes in bowel habits:

  • When did the changes start?
  • What makes it better?
  • What makes it worse?
  • Any social life changes or stressors?

This condition is VERY closely associated with stress levels. If stressed, bowels become very active (or shut down, then evacuate).

Common Comorbid Conditions

  • Gastroesophageal reflux disease (GERD)
  • Fibromyalgia
  • Interstitial cystitis
  • Chronic migraines
  • Anxiety disorders
  • Depression

Diagnostic Evaluation

Diagnosis of Exclusion: IBS is diagnosed primarily by ruling out other organic diseases. There is no definitive test for IBS; diagnosis is based on symptom pattern and exclusion of red flag conditions like inflammatory bowel disease, celiac disease, or colorectal cancer.
Diagnostic Test Purpose
CBC and C-Reactive Protein Rule out inflammation and infection
Fecal Calprotectin Test Excludes inflammatory bowel disease (IBD)
Stool Studies Rule out infections, parasites, blood
Colonoscopy Visualize colon, exclude structural abnormalities and IBD

Management and Treatment

Primary Goals

Lifestyle Modifications

  1. Stress Reduction
    • Cognitive-behavioral therapy (CBT)
    • Mindfulness and relaxation techniques
    • Yoga and meditation
    • Regular exercise
  2. Adequate Sleep
    • 7-9 hours nightly
    • Consistent sleep schedule
    • Sleep hygiene practices
  3. Regular Physical Activity
    • 30 minutes moderate exercise most days
    • Improves gut motility and reduces stress
    • Walking, swimming, cycling recommended

Dietary Management

Soluble Fiber Supplementation

Low-FODMAP Diet

FODMAP ACRONYM

Fermentable Oligosaccharides, Disaccharides, Monosaccharides, And Polyols – poorly absorbed short-chain carbohydrates that can trigger IBS symptoms through fermentation and osmotic effects in the gut.

CRITICAL: FODMAP Diet Composition:

  • HIGH PROTEIN
  • LOW FAT
  • HIGH FIBER
  • NOT no carbs - carbs should just not be the majority of the diet

Foods that ferment and should be limited: Excess fruits (especially citrus), milk/dairy, yeast products, sugar. The goal is to avoid foods that ferment in the stomach.

Moderation is Key - Real World Example: If a patient loves grapes and eats 10 pounds a day, we don't eliminate grapes completely. Instead, we switch to 10 pounds per WEEK, making grapes a dessert/treat paired with water. It's about balance, not complete restriction. Progress, not perfection!
FOODS TO RESTRICT ON LOW-FODMAP DIET

High-FODMAP Foods to Avoid

  • Fermentable foods: Beans, lentils, cabbage
  • Lactose: Milk, ice cream, soft cheeses
  • Fructose: Apples, honey, high-fructose corn syrup
  • Polyols: Sugar alcohols, stone fruits, mushrooms

Additional Triggers

  • Wheat and gluten-containing grains
  • Onions and garlic
  • Certain vegetables (cauliflower, asparagus)
  • Artificial sweeteners
Low-FODMAP Implementation: This diet should be done in three phases: (1) Elimination of high-FODMAP foods for 4-6 weeks, (2) Systematic reintroduction of one FODMAP group at a time to identify triggers, (3) Personalization of long-term diet based on individual tolerance. Consider referral to a registered dietitian for proper guidance.

Pharmacological Management

For IBS-D (Diarrhea-Predominant)

MEDICATION PROFILE

Loperamide (Imodium, Diamode)

Mechanism: Slows intestinal motility and reduces fluid secretion into the bowel, resulting in firmer, less frequent stools.

Dosing: Take as needed for diarrhea episodes; do not exceed maximum daily dose

Nursing Considerations:

  • Monitor for constipation and abdominal discomfort
  • Educate patients to stay well-hydrated
  • Use with caution in elderly patients
  • Should not be used if fever or bloody stools present (may indicate infection)

For Severe IBS-C (Constipation-Predominant)

MEDICATION PROFILE

Lubiprostone (Amitiza)

Mechanism: Activates chloride channels in the intestinal lining, increasing fluid secretion into the bowel lumen and improving stool passage.

Administration: Take orally with food and a full glass of water

Nursing Considerations:

  • Monitor for nausea (most common side effect)
  • Assess for diarrhea and adjust dosing if needed
  • Watch for abdominal pain and headache
  • Taking with food reduces nausea

For Abdominal Cramping and Spasms

MEDICATION PROFILE

Oxybutynin

Classification: Antispasmodic

Mechanism: Stops unnecessary gut spasms - helps when stomach is making you feel constipated AND having diarrhea at the same time

Use in IBS: When spasms occur due to IBS, helps reduce involuntary contractions

MEDICATION PROFILE

Dicyclomine (Bentyl)

Classification: Anticholinergic/antispasmodic

Mechanism: Relaxes smooth muscle of the GI tract, reducing spasms and cramping pain

Nursing Considerations:

  • Common side effects: Dry mouth, dizziness, blurred vision, drowsiness, constipation
  • Caution patients about drowsiness – avoid driving until effects known
  • Use with caution in elderly (increased anticholinergic sensitivity)
  • Contraindicated in glaucoma, urinary retention, severe ulcerative colitis
  • Encourage adequate hydration and sugar-free gum/candy for dry mouth

Adjunctive Therapies

Therapy Mechanism/Benefit Considerations
Antidepressants
(Low-dose TCAs or SSRIs) 		Regulate gut motility, reduce visceral hypersensitivity, decrease pain perception Benefits seen at doses lower than antidepressant effect; takes 2-4 weeks
Peppermint Oil Natural antispasmodic that reduces bloating and intestinal spasms Use enteric-coated capsules; may worsen GERD
Probiotics
(Lactobacillus, Bifidobacterium) 		Restore healthy gut microbiome, reduce gas and bloating Effects vary by strain; may take several weeks to see benefit

Nursing Education and Self-Care

PATIENT TEACHING PRIORITIES
  1. Bowel Habit Diary
    • Use Bristol Stool Form Scale to track stool consistency
    • Record timing, triggers, and associated symptoms
    • Helps identify patterns and dietary triggers
  2. Food Diary
    • Document all food and beverage intake
    • Note timing of symptoms in relation to meals
    • Identify problem foods through systematic elimination
  3. Dietary Habits
    • Eat regular meals at consistent times
    • Avoid skipping meals
    • Eat slowly and chew food thoroughly
    • Stay well-hydrated (8+ glasses water daily)
  4. Lifestyle Modifications
    • Discourage alcohol use – irritates gut
    • Discourage cigarette smoking – worsens symptoms
    • Emphasize importance of good sleep hygiene
    • Encourage stress management techniques
    • FIBER in different forms - not just Metamucil! Natural whole foods
    • Ambulation and mobility - get moving! Even if starting slowly
    • Strengthen core muscles - helps support abdominal area and prevents stretching
  5. Bowel Health Diary - CRITICAL
    • Track what they ate
    • Record how they felt afterward
    • Document poop appearance and consistency
    • Note timing and any associated symptoms
    • This helps healthcare team identify patterns and triggers
  6. Toilet Sitting Time - IMPORTANT SAFETY
    • NO prolonged sitting (15-20 minutes MAXIMUM)
    • Why this matters:
      • Causes hemorrhoids
      • Hip issues (changes circumference)
      • Spine issues
    • Educate patients to plan bathroom visits rather than sitting for extended periods
Inflammatory Markers: For IBS workup, expect to see labs checking for inflammation:
  • CRP (C-Reactive Protein): Inflammatory marker
  • ESR (Erythrocyte Sedimentation Rate): Another inflammatory marker
  • If physician orders these, they suspect an inflammatory process
  • Also check stool studies and other tests to rule out infection
Mind-Gut Connection: IBS is strongly influenced by the gut-brain axis. Psychological stress directly affects gut motility and sensitivity. Cognitive-behavioral therapy (CBT), mindfulness-based stress reduction, and gut-directed hypnotherapy have all shown effectiveness in managing IBS symptoms. Encourage patients to address both physical and psychological aspects of the condition.
STRUCTURAL GI DISORDER

Diverticular Disease

KEY TERMINOLOGY

Diverticula: Outpouchings or bulges of the intestinal mucosa through weakened areas in the muscle layer of the bowel wall. Most commonly occur in the sigmoid colon.

Diverticulosis: Presence of multiple non-inflamed diverticula. Often asymptomatic and discovered incidentally.

Diverticulitis: Inflammation or infection of one or more diverticula, requiring medical intervention.

Epidemiology

Pathophysiology

Diverticula form when increased intraluminal pressure forces the intestinal mucosa through natural weak points in the bowel wall (where blood vessels penetrate). When bowel contents become trapped in these pouches, bacterial overgrowth leads to inflammation and infection – resulting in diverticulitis.

PROGRESSION TO DIVERTICULITIS
  1. Diverticula Formation

    Low-fiber diet → hard stools → increased colonic pressure → mucosal herniation

  2. Obstruction

    Fecal matter or undigested food becomes trapped in diverticulum

  3. Inflammation and Infection

    Bacterial overgrowth → inflammation → potential perforation

Complications of Diverticulitis

Abscess Formation

  • Tender, palpable abdominal mass
  • Fever and leukocytosis
  • May require CT-guided drainage

Peritonitis

  • Severe abdominal pain
  • Rigid, board-like abdomen
  • Fever and systemic toxicity
  • Requires emergency surgery

Fistula Formation

  • Colovesicular: Colon to bladder (pneumaturia, fecaluria, recurrent UTIs)
  • Colovaginal: Colon to vagina (passage of gas/feces through vagina)

Rectal Bleeding

  • Inflammation erodes arterial branches
  • Can be painless and significant
  • Usually stops spontaneously
Microperforation Risk: Small perforations in inflamed diverticula can lead to abscess formation or fistula development. Large perforations cause generalized peritonitis and sepsis, which is life-threatening and requires emergency surgical intervention.

Risk Factors and Clinical Presentation

Contributing Factors

Dietary

  • Low-fiber diet
  • High red meat consumption
  • High-fat diet
  • High-sugar intake

Other Risk Factors

  • Obesity
  • Cigarette smoking
  • Chronic NSAID use
  • Family history
  • Sedentary lifestyle
Diet Connection: Low-fiber diets result in sluggish colon movement and increased intraluminal pressure needed to propel hard stool. This chronic high pressure is the primary mechanism for diverticula formation. Once diverticula exist, they don't resolve, but high-fiber diet can prevent progression and complications.

Signs and Symptoms of Diverticulitis

Diagnostic Evaluation

Diagnostic Test Purpose/Findings Timing
Colonoscopy Primary diagnostic tool for diverticulosis; visualizes diverticula Not performed during acute diverticulitis (perforation risk)
Hemoglobin/Hematocrit Assess for anemia if bleeding present As indicated by symptoms
WBC Count Elevation indicates infection/abscess During acute episode
Urinalysis and Culture Evaluate for fistula if pneumaturia or recurrent UTIs When fistula suspected
CT with Contrast Confirms diverticulitis, identifies complications (abscess, perforation) Gold standard for acute diverticulitis
Abdominal X-rays Identify free air (perforation) or obstruction When perforation suspected

Modified Hinchey Classification System

SEVERITY STAGING

The Modified Hinchey Classification categorizes diverticulitis severity to guide treatment decisions:

  • Stage 0: Mild clinical diverticulitis (outpatient management possible)
  • Stage Ia: Confined pericolic inflammation or phlegmon
  • Stage Ib: Confined pericolic abscess
  • Stage II: Distant abscess (pelvis, retroperitoneum)
  • Stage III: Generalized purulent peritonitis
  • Stage IV: Fecal peritonitis (requires emergency surgery)

Management of Diverticulitis

Conservative Medical Management (Mild Cases)

  1. Bowel Rest
    • NPO status to rest the bowel completely
    • Administer intravenous fluids for hydration and electrolytes
    • Monitor for vomiting or increasing abdominal distention
    • May require nasogastric (NG) suctioning if obstruction or severe ileus present
  2. Antibiotic Therapy
    • Broad-spectrum antibiotics to cover gram-negative and anaerobic bacteria
    • Common regimens:
      • Ampicillin/sulbactam (Unasyn)
      • Ticarcillin/clavulanate (Timentin)
      • Ciprofloxacin + metronidazole
    • Typically 7-10 days duration
  3. Abscess Drainage
    • CT-guided percutaneous drainage for accessible abscesses
    • Avoids need for immediate surgery in many cases
    • Monitor drainage output and characteristics

Surgical Intervention

INDICATIONS FOR SURGERY
  • Perforation with peritonitis (emergency)
  • Large abscess not amenable to drainage
  • Fistula formation
  • Obstruction that doesn't resolve
  • Recurrent attacks (typically after 2-3 episodes)
  • Immunocompromised patients (lower threshold)

Surgical options: Bowel resection with primary anastomosis (reconnection) if possible, or temporary colostomy if bowel cannot be safely reconnected due to inflammation/infection.

Nursing Management During Acute Episode

PRIORITY NURSING INTERVENTIONS
  • Monitor vital signs for fever, tachycardia, hypotension (sepsis indicators)
  • Assess abdomen frequently for increasing pain, distention, rigidity
  • Maintain NPO status and IV hydration as ordered
  • Administer antibiotics on schedule
  • Monitor intake and output strictly
  • Provide pain management (avoid morphine initially – may mask symptoms)
  • Position for comfort – may prefer side-lying or semi-Fowler's
  • Report signs of complications immediately:
    • Worsening or spreading abdominal pain
    • Increased abdominal rigidity
    • Hemodynamic instability
    • Decreased urine output

Long-Term Prevention

Patient Education

Prevention is Key: Once diverticula form, they are permanent. However, a high-fiber diet can prevent progression and significantly reduce the risk of diverticulitis episodes. Emphasize to patients that lifestyle modifications are lifelong commitments to prevent complications.
MALIGNANCY

Colorectal Cancer

OVERVIEW

Colorectal Cancer: Malignant tumors arising from the epithelial lining of the colon or rectum. Often begins as benign polyps that undergo malignant transformation over time. Tumors can obstruct the bowel lumen or perforate through the bowel wall, leading to life-threatening complications.

Epidemiology and Risk Factors

Dietary and Lifestyle Factors

High-Risk Diet

  • High fat
  • High protein (especially red/processed meat)
  • Low fiber

Alcohol Consumption

  • Males: ≥2 drinks daily
  • Females: >1 drink daily

Other Risk Factors

  • Obesity
  • Type 2 diabetes
  • Smoking

Important Health History Factors

KEY ASSESSMENT QUESTIONS
  • Fatigue: May indicate chronic blood loss and anemia
  • Abdominal or rectal pain: Location and characteristics
  • Elimination patterns: Changes in bowel habits, stool characteristics
  • History of IBD: Crohn's disease or ulcerative colitis increase risk
  • Pelvic radiation: Previous treatment for other cancers
  • Family history (30% of cases):
    • Colorectal cancer in first-degree relatives
    • Lynch syndrome (hereditary nonpolyposis colorectal cancer)
    • Familial adenomatous polyposis (FAP) – precancerous condition with hundreds to thousands of polyps
  • Ethnicity: African Americans and Ashkenazi Jews at higher risk

Clinical Presentation by Lesion Location

Location Manifestations Characteristics
Right-Sided Lesions
(Ascending colon)
  • Abdominal pain (vague)
  • Melena (black, tarry stools)
  • Anemia from chronic blood loss
  • Weakness and fatigue
 Stool is liquid in ascending colon; blood has time to be digested, resulting in melena rather than bright red blood
Left-Sided Lesions
(Descending/sigmoid colon)
  • Bowel obstruction symptoms
  • Hematochezia (bright red blood in stool)
  • Cramping
  • Change in stool caliber (pencil-thin)
 Stool is more formed in left colon; tumor can cause obstruction. Blood is fresh and not digested.
Rectal Lesions
  • Tenesmus (painful straining)
  • Rectal pain
  • Feeling of incomplete evacuation
  • Alternating constipation/diarrhea
  • Bright red blood in stool
 Tumor in rectum causes sensation of fullness and urgency even when rectum is empty
Right vs. Left Symptoms: Right-sided tumors present late with vague symptoms because the ascending colon has a large diameter and liquid stool, allowing tumor growth without obstruction. Left-sided tumors present earlier with more specific symptoms because the descending colon is narrower with formed stool, leading to obstruction symptoms sooner.

Screening and Diagnosis

Screening Recommendations

STANDARD SCREENING PROTOCOL

Colonoscopy: Preferred screening tool for colorectal cancer

  • Begin at age 50 for average-risk individuals
  • Earlier and more frequent for those with:
    • Family history of colorectal cancer
    • Personal history of IBD
    • Known genetic syndromes (Lynch, FAP)
  • Repeat every 5-10 years if normal
  • Polyps can be removed during screening procedure (polypectomy)
  • Biopsy and "tattooing" of concerning areas for surgical identification

Diagnostic Workup

Test Purpose
Colonoscopy with Biopsy Definitive diagnosis; tissue for pathology; polyp removal
Genetic Testing Screen for Lynch syndrome and FAP in high-risk patients
CBC Assess for anemia from chronic blood loss
Liver Function Tests Evaluate for liver metastasis
Baseline CEA Level Carcinoembryonic antigen – tumor marker for monitoring disease presence and progression
CT Scans Chest, abdomen, and pelvis with contrast to assess for metastases and staging
CEA Monitoring: Carcinoembryonic antigen (CEA) is elevated in many patients with colorectal cancer. While not specific enough for diagnosis, it's valuable for monitoring treatment response and detecting recurrence. Rising CEA levels after treatment may indicate cancer recurrence before symptoms appear.

Treatment Approach

Treatment typically involves a combination of surgery, radiation therapy, and chemotherapy, with the specific approach depending on cancer stage, location, and patient factors.

Surgical Options

SURGICAL INTERVENTIONS
  • Laparoscopic surgery: Preferred when possible
    • Shorter hospital stays
    • Fewer complications
    • Faster recovery
    • Typically performed for Stage I, II, and III disease
  • Bowel resection: Removal of affected bowel segment with surrounding lymph nodes
  • Ostomy creation when bowel cannot be reconnected:
    • Colostomy: Portion of large intestine removed; stoma brings healthy end of colon to abdominal surface
    • Ileostomy: Entire colon or terminal ileum removed; stoma brings end of ileum to abdominal surface

Colostomy

  • Large intestine brought to surface
  • Stool consistency varies by location:
    • Ascending: Liquid
    • Transverse: Soft, semi-formed
    • Descending/Sigmoid: Formed
  • May be temporary or permanent

Ileostomy

  • Terminal ileum brought to surface
  • Continuous liquid stool output
  • Higher volume (600-1200 mL/day)
  • Greater risk for fluid/electrolyte imbalance
  • Usually permanent

Post-Operative Nursing Management for Ostomy Patients

Immediate Post-Operative Care

  1. Encourage Early Ambulation
    • Administer pain medication 30 minutes prior to activity
    • Begin ambulation as soon as medically stable (usually POD 1)
    • Prevents complications: pneumonia, DVT, ileus
  2. Monitor Stoma Appearance
    • Normal appearance: Pink to bright red, moist, shiny
    • Assess for complications:
      • Dark red, purple, or black color (ischemia/necrosis)
      • Pale or dusky appearance (poor perfusion)
      • Excessive swelling or retraction
    • Measure stoma size for proper appliance fitting
  3. Assess Peristomal Skin
    • Check for excoriation, redness, breakdown
    • Caused by poor appliance fit or stool contact with skin
    • Consult WOC (Wound, Ostomy, Continence) nurse if issues arise
  4. Apply Clear Pouch Initially
    • Clear plastic bag allows visualization of stoma without removal
    • Monitor stoma color and output easily
    • Transition to opaque pouching system when stable

Output Monitoring

EXPECTED OSTOMY OUTPUT
Ostomy Type Expected Output Consistency
Ileostomy 600-1200 mL daily Continuous liquid stool
Colostomy (Transverse) 200-600 mL daily Soft, semi-formed stools
Colostomy (Descending/Sigmoid) 200-600 mL daily Formed stools (closer to normal)

Monitoring for Ostomy Complications

Complication Signs/Symptoms Management
Peristomal Skin Irritation Redness, excoriation, burning, itching around stoma Ensure well-fitting pouching system; consult WOC nurse; skin barrier products
Stomal Stenosis Narrowing of stoma opening; difficulty with output May require dilation or surgical revision
Stomal Prolapse Protrusion of bowel through stoma May reduce spontaneously or require surgery
Stomal Retraction Stoma pulls below skin level Specialized pouching systems; may need surgical revision
Excessive Diarrhea High-volume liquid output (especially ileostomy) Supplemental water, sodium, and potassium; antidiarrheal medication
Urinary Calculi Kidney stones from dehydration Encourage adequate hydration (ileostomy patients at highest risk)
Gallstones (Cholelithiasis) More common in IBD patients with ileostomy Monitor for RUQ pain, nausea; may require cholecystectomy
Fluid and Electrolyte Balance: Ileostomy patients are at high risk for dehydration and electrolyte imbalances due to continuous liquid output and loss of the colon's water-absorbing capacity. Monitor for signs of dehydration (decreased urine output, dizziness, weakness) and hypokalemia (muscle weakness, arrhythmias). Emphasize adequate hydration and electrolyte-rich fluids.

Pouching System Management

POUCHING SYSTEM COMPONENTS
  • Pouch: Collects fecal output; may be one-piece or two-piece system
  • Solid skin barrier: Protects peristomal skin from stool contact
  • Adhesive: Secures system to skin

WOC Nurse Role: Wound, Ostomy, and Continence nurses are specialized in selecting and fitting appropriate pouching systems. They provide expert consultation for complex cases and patient education.

Appliance Care and Maintenance

Dietary Management for Ostomy Patients

Initial Post-Operative Diet

Foods and Their Effects

Deodorizing Foods

  • Spinach
  • Parsley
  • Buttermilk
  • Yogurt

Odor-Causing Foods

  • Asparagus
  • Cabbage
  • Onions
  • Fish
  • Eggs
  • Garlic

Thicken Stool

  • Rice
  • Mashed potatoes
  • Applesauce
  • Bananas
  • Cheese
  • Pasta

Loosen Stool

  • Leafy green vegetables
  • Raw fruits and vegetables
  • Prune juice
  • Spicy foods

Additional Dietary Considerations

Gas-Producing Foods: Beans, carbonated beverages, beer, broccoli, Brussels sprouts, cabbage, cauliflower, onions, and dairy products can increase gas and cause pouch ballooning. Patients should identify their personal triggers and moderate intake of these foods.

Psychosocial Support and Adaptation

EMOTIONAL AND SOCIAL CONCERNS

Ostomy surgery represents a major life change with potential impacts on:

  • Body image: Altered appearance and concerns about visibility
  • Self-esteem: Feelings of being "different" or "damaged"
  • Relationships: Concerns about intimacy and partner acceptance
  • Fertility: Questions about pregnancy and childbirth (usually possible)
  • Sexuality: Worries about sexual function and attractiveness
  • Social activities: Fear of odor, leakage, or appliance visibility
  • Employment: Concerns about work activities and bathroom access

Nursing Interventions for Emotional Support

  1. Early Education
    • Begin teaching about ostomy care as soon as patient is ready
    • Hands-on practice promotes confidence and acceptance
    • Involve family members/support persons with patient permission
  2. Encourage Expression of Feelings
    • Validate that grief and adjustment are normal
    • Allow time to process the change
    • Listen without judgment
  3. Connect with Support Resources
    • United Ostomy Associations of America (UOAA): Peer support, education, local chapters
    • WOC Nurses: Ongoing expert guidance and troubleshooting
    • Ostomate visitors: People living successfully with ostomies who can offer hope and practical tips
  4. Address Specific Concerns
    • Provide information on intimacy and sexuality with ostomy
    • Discuss clothing options that conceal appliance
    • Reassure about ability to participate in most activities (including swimming, sports)
    • Normalize the adjustment process
Adjustment Period: Most patients experience significant emotional distress in the first 3-6 months after ostomy surgery. This is normal. Emphasize that adaptation improves with time, practice, and support. Many ostomates report returning to full, satisfying lives including relationships, careers, and physical activities.

Follow-Up Care for Colorectal Cancer

SURVEILLANCE SCHEDULE

Stage II and III Patients: Require intensive follow-up due to risk of recurrence

  • CEA testing: Every 3-6 months for 5 years
  • CT scans: Annual imaging of abdomen and chest for 3 years
  • Colonoscopy: At 1 year post-operatively, then every 5 years if normal
  • Physical examination: Every 3-6 months for first 2 years, then every 6 months for years 3-5
Recurrence Risk: Most colorectal cancer recurrences happen within the first 2-3 years after treatment. Close surveillance during this period allows for early detection and intervention, which significantly improves outcomes.
INTEGRATION

Key Takeaways

Emergency Conditions

  • Appendicitis: Classic RLQ pain, rebound tenderness, requires immediate surgery
  • Ruptured appendix: Peritonitis emergency
  • Perforated diverticulitis: Generalized peritonitis, sepsis risk
  • All require rapid assessment and intervention

Chronic Management

  • IBS: Functional disorder requiring lifestyle modification, stress management, dietary changes
  • Diverticulosis: Prevention focus with high-fiber diet
  • Post-ostomy care: Lifelong adaptation and monitoring

Universal Nursing Priorities

ACROSS ALL CONDITIONS
  • Thorough assessment: Abdominal examination, pain characteristics, elimination patterns
  • Fluid and electrolyte monitoring: Critical in bowel disorders
  • Nutrition support: Disease-specific dietary modifications
  • Pain management: Balanced with need for accurate assessment
  • Patient education: Prevention, self-care, when to seek help
  • Psychosocial support: GI disorders significantly impact quality of life
  • Complication prevention: Early ambulation, DVT prophylaxis, infection control

Critical Medication Knowledge

Medication Key Points
Loperamide (Imodium) IBS-D; monitor for constipation; ensure hydration
Lubiprostone (Amitiza) Severe IBS-C; take with food/water; monitor for nausea
Dicyclomine (Bentyl) Antispasmodic; anticholinergic side effects; caution in elderly
Broad-spectrum antibiotics Diverticulitis; 7-10 days; cover gram-negative and anaerobes
Diphenoxylate/atropine Ostomy patients; thickens stool; controls odor

Red Flags Requiring Immediate Attention

  • Signs of perforation: Sudden severe pain, rigid abdomen, fever, hypotension
  • Signs of obstruction: Absent bowel sounds, severe distention, vomiting
  • Significant GI bleeding: Hematemesis, large-volume hematochezia, hemodynamic instability
  • Stomal ischemia: Dark, dusky, or black stoma color
  • Sepsis indicators: Fever, tachycardia, hypotension, altered mental status
Final Thought: Digestive disorders range from acute surgical emergencies to chronic conditions requiring lifelong management. Success depends on thorough assessment, timely intervention, comprehensive patient education, and attention to both physical and psychosocial needs. The nurse's role encompasses acute care, chronic disease management, patient advocacy, and education – making nursing essential to positive outcomes across the continuum of GI care.