Intestinal Disorders Phyllis LeBlanc, PhD, RN Revised By: Tabitha Jones-Thomas, MSN, RN 1) Overview: 1.

The client with an intestinal disorder will usually have a problem with bowel elimination. 2. Manifestations of intestinal disorders vary according to: 1) which function (motility, digestion, or absorption) is disturbed 2) the cause of the disturbance Anatomy and Physiology (A) Small Intestine (B) Accessory Digestive Organs (C) Large Intestine
**Prof Insert Alert The organs of the digestive system are grouped: (1) Alimentary canal (GI tract)= consisting of the mouth, esophagus, stomach, and small and large intestines (2) The Accessory Digestive Organs= including the liver, pancreas, gallbladder and ductal system.

2)

1.

Small Intestine 1) Begins at pyloric sphincter and ends at the ileocecal valve 2) Consists of duodenum, jejunum, and ileum 3) Is about 20 feet long 4) Functions/Characteristics of the Small Intestine: a) Primary site of digestion and absorption of nutrients b) Is lined with villi that contain capillaries and lymphatics c) Motor activity includes mixing and peristalsis Accessory Digestive Organs 1) Liver 2) Pancreas 3) Gallbladder 4) Ductal System
**Prof Insert AlertPancreatic enzymes and bile are excreted into the duodenum (beginning of small intestines) to the common bile duct.

2.

3.

Large Intestine 1) Consists of the cecum, appendix, colon, rectum, and anus 2) Is about 5 feet long 3) Segments of the colon are the ascending colon, transverse colon, descending colon, and sigmoid colon 4) Functions of the Large Intestine: 1. absorption of water and electrolytes 2. synthesis of Vitamin K 3. storage and elimination of fecal material 5) The anus has an internal involuntary sphincter and an external voluntary sphincter 6) The defecation reflex is initiated when feces enter the rectum and stretch the rectal wall

1.

Diagnostic Tests Used to Identify Intestinal Disorders a. Stool for Occult Blood Advise patient to avoid red meat, iron, anticoagulants, aspirin, or Vitamin C for 1 to 3 days.
*This is analysis of stool for blood using a reagent such as guaiac hemoccult or hematest. *Red meats should be avoided for 3 days before the test. Otherwise, false-positive results could be obtained because red meats contain animal hemoglobin. *Avoid drugs that may cause false-negative results.

b.

Small Bowel Follow Through Contrast Enhanced X-Ray Study Also referred to as Upper GI Series, Small Bowel Series or Barium Swallow

*The Small Bowel Follow Through is performed to identify abnormalities in the small bowel. Usually the pt is asked to drink barium; in patients who cannot drink, barium can be injected through a NG Tube. X-ray films are then obtained at timed intervals. (usually 30 minutes to 1 hour) to follow the progression of barium through the small bowel. *Significant delays in barium transit time may occur as a result of both malignant and benign forms of partial obstruction or diminished intestinal motility (ileus). *The flow of barium is faster in patients who have hypermotility of the small bowel (ex: malabsorption syndrome). *Failure of the progression of barium can be seen in patients with a complete mechanical small bowel obstruction. *SBF also helpful in detecting fistulas.

Nursing Considerations for Small Bowel Series

1. 2. 3. 4. 5. Procedure involves oral administration of contrast medium followed by fluoroscopy Informed consent Instruct patient on NPO for 8 hours before exam Fluids and laxative after procedure Expect stools to be chalky white

6.

*Prof Insert AlertPush Fluids and administer enemas per physicians order prevent obstruction or impaction!!!

c.

Lower GI Series Barium Enema X-Ray Nursing Considerations for Lower GI Series 1. Procedure involves administration of contrast medium via an enema and followed by fluoroscopy 2. Informed consent 3. Instruct on clear liquid diet evening before procedure 4. NPO for 8 hours before exam 5. fluids and laxative post-procedure
**Prof Insert Alert

* The study consists of a series of x-ray films that visualize the colon. It is used to demonstrate

the presence and location of polyps, tumors, and diverticula. *Therapeutically, bleeding from diverticula can cease after a BE. The BE is occasionally used to assess filling of the appendix. *When clinical findings suggest appendicitis, failure of the appendix to fill with barium may support the diagnosis. *Barium enema may be used to reduce nonstrangulated ileocolic intussusception in children. d. Double contrast barium enema
**Prof Insert Alert

In this procedure, Air is injected into the colon after instillation of barium. This provides air contrast to the barium. With air contrast, the colonic mucosa can be much more accurately visualized. This is called air contrast barium enema or double contrast barium enema and is used especially when polyps are suspected. Abdominal bloating and rectal pressure occur during instillation of air and barium. Have pt to ambulate frequently in addition to pushing fluids, administering laxatives and enemas.

e.

Colonoscopy Direct visualization of the large intestines (colon) from anus to cecum using a lighted scope Informed consent Instruct on clear liquids for 1-2 days NPO for 8 hours before exam Laxative evening before exam Nursing Considerations for Colonoscopy 1. Sedation is usually given 2. Abd. cramping may occur post-procedure 3. Monitor for rectal bleeding / perforation 4. Arrange for transportation home Biopsy may be taken and polyps may be removed

*Laxative (magnesium citrate or Golytely) on evening before exam; explain the insertion of scope through rectum; sedation is usually given during procedure; a biopsy may be taken and polyps may be removed; may have abdominal cramping after procedure b/c bowel was inflated with air; arrange for transportation home ***Monitor for rectal bleeding and signs of perforation. Vital signs.

f.

g. h. i.

**Prof Insert Alert Computed tomography (CT) scan Magnetic resonance imaging (MRI) Ultrasound a. noninvasive examination to assess tumor depth and involvement of other organs by direct extension or metastasis ***For abdominal ultrasound, instruct NPO for 8 hours and bowel must be clean ***For MRI, instruct NPO

Sigmoidoscopy Direct visualization of the sigmoid colon, rectum, and anal canal using a lighted scope Informed consent Laxative evening prior to **Prof Insert Alert exam and enema on Sigmoidoscopy can be therapeutic for removal of polyps and removal of morning of exam hemorrhoids. Pt may ingest light breakfast on the morning of the test. Biopsy may be taken and Usually two fleets enemas on the morning of the test are suffiecient. An polyps may be removed oral cathartic is usually required to examine as far as 60cm. Report bleeding and fever Sigmoidoscopy: post-procedure Direct visualization of the sigmoid colon, rectum, and anal canal Computed Tomography using a lighted scope Magnetic Resonance Imaging (MRI) Informed consent Ultrasound Instruct to take a laxative on evening before exam Enema on morning of procedure

***Explain the insertion of scope through rectum and knee

chest positioning or positioning on left side; a biopsy may be taken and polyps may be removed; ***Report any: abdominal pain, fever, chills, or rectal bleeding after procedure.

INTESTINAL DISORDERS
APPENDICITIS = Inflammation of the Appendix
Anatomy & Physiology Appendix is a small fingerlike structure that is attached to the cecum just below the ileocecal valve. Fills with food and empties regularly into the cecum. No purpose really to serve. B/c the appendix empties inefficiently and its lumen is small: (1) prone to obstruction (2) vulnerable to infection. Occurs in about 6 % of population. Peak is between ages 11-30, equally among sexes. Appendix becomes inflamed & edematous as a result of becoming kinked or occluded a mass of hard stool, tumor or foreign body. Eventually the inflamed appendix will fill with pus. Most Common causes: o a fecalith (accumulated feces) o foreign bodies o tumor of the cecum or appendix o intramural thickening caused by lymphoid hyperplasia. o Thickening of the lymph node. Pain, localizes to right lower abdomen. Guarding of abdomen, local tenderness is elicited at McBurneys point when pressure is applied. McBurneys point is between the umbilicus and the interior superior iliac spine. Decreased bowel sounds; Fever; Nausea vomiting; Increased WBC count; Rebound tenderness production or intensification of pain when pressure is released. Rovsings sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant. Diagnosis is based on complete physical exam and Lab and X-ray findings. CT Scan & Xrays may reveal distention of bowel. CBC reveals increased WBC count. Leukocyte and neutrophil count may be increased. Perforation of the appendix, which can lead to peritonitis or an abscess. 1. MedicalAntibiotics and intravenous fluids are administered until surgery performed. Analgesics may be administered for pain. If paralytic ileus is suspected the physician will order an NG tube. NO enemas or laxatives are given to the PT with appendicitis this may cause it to perforate. 2. Surgical Appendectomy=Surgical removal of the appendix is performed ASAP to decrease risk of perforation. 1. Assessment Vital signs, Bowel sounds, Assess pain, Nausea & vomiting, hemorrhage. a. If peritonitis was suspected PT will probably have a drain postoperatively, assess incision. 2. Nursing DxAnxiety, Altered Comfort, Risk for Fluid Volume Deficit, Risk for Infection. 3. Planning a. Postoperatively place PT in semifowlers position, this position will reduce the tension on the incision and assist in reducing pain. b. Administer fluids as tolerated. 4. GoalsPT may be discharged if surgery is uncomplicated, temp WNL and pain tolerable with medication. 5. Teaching (Discharge) Teach to monitor incision, S&S of infection, educate on medication, discuss postop activity, and follow up appointment.

Pathophysiology

Clinical Manifestations

Diagnostic Studies

Potential Complications Gerontological Considerations Therapeutic Management

Nursing Management

Peritonitis= Inflammation of the peritoneum, the serous membrane covering the viscera . A. Peritonitis is caused by the leakage of contents from the abdominal cavity, usually as a result of inflammation, infection, ischemia, trauma, or tumor perforation. B. The immediate response of the intestinal tract is hypermotility, soon followed by paralytic ileus with an accumulation of air and fluid in the bowel. C. Four types of bacteria responsible for peritonitis: E. Coli; psedomonus; proteus; klebsiblla D. Occurs about three times more often in women than in men . E. Primary- Acute, spontaneous condition, relatively rare (e.g. introduced in females through uterine tubes or blood due to pathogenic bacteria such as strep, pneumococci or gonococci. Examples: complications of abdominal surgery-abdominal trauma; compromised patients. F. Secondary- Contamination of the peritoneal cavity by GI fluids and microorganisms. Peritoneal dialysis: tube inserted in the stomach and do fluid exchange overnight causes increase in risk of infection.

Clinical Manifestations (Peritonitis)-these patients tend to be very still with legs drawn in; loss of liver dullness may indicate free air in the abdomen. (1) Abdominal pain (2) Rebound tenderness and ileus may be present (3) Percussion: resonance and tympany due to paralytic ileus (4) Auscultation: decreased bowel sounds (5) N/V (6) Elevated temp (7) Dehydration (8) Weakness, pallor, diaphoresis (9) Ascities (10) *****A pt who is diabetic will not have these classic symptoms usually due to some type of neuropathy. Peritonitis Management (1) Broad spectrum antibiotics (ex. gentamycin; streptomycin; mefoxin; tequin; cypro) all are administered IVPB:Treatment for the inflammatory condition (2) Bedrest, NPO status, respiratory support (3) I.V fluids and electrolytes (Isotonic solution) (4) Analgestics for pain (5) Possible paracentesis to remove accumulating fluid if they have ascites (6) NG intubation to decompress the bowel Nursing Diagnosis (Peritonitis) G. Acute pain related to peritoneal inflammation H. Deficient Fluid Volume related to vomiting and interstitial fluid shift I. Imbalanced Nutrition: Less than body requirements related to GI symptoms Brain Exercise: *What laboratory data result would serve to alert you to a serious complication of peritonitis? a. A positive blood culture b. A WBC count of 20,000 c. An elevated serum amylase level d. The presence of WBCs in the urine

IRRITABLE BOWEL SYNDROME

Irritable bowel syndrome (IBS) is a functional disorder characterized by abdominal pain and altered bowel habits.

Anatomy & Physiology

Pathophysiology

Clinical Manifestations

Diagnostic Studies

Affects about 15% of US population Occurs about three times more often in women than in men. Cause of IBS is unknown; Contributing factors may include stress, diet, and psychosocial factors. The bowels contract too hard or not hard enough and cause food to move too quickly or too slowly something may trigger increased sensitivity in the bowel. Altered central nervous system regulation of motor and sensory functions of the bowel: a. abnormal intestinal motility b. lower visceral pain threshold Abdominal pain Intermittent and recurrent lower abdominal pain associated with a change in bowel function (diarrhea, constipation, or alternating diarrhea and constipation). Constipation, diarrhea, or both Abnormal stool consistency Mucous stools Abdominal bloating Excessive flatulence Sensation of incomplete evacuation *May have abdominal distention, excessive flatulence, sensation of incomplete evacuation relieved after emptying the bowel ***Rule out an organic problem: (Diagnostic tests to rule out Dxs such as peptic ulcer disease, colon cancer, malabsorption syndrome) 1. Fecal occult blood 2. Complete blood count (CBC) 3. Erythrocyte sedimentation rate (ESR)= if sed rate is elevated it is not IBS 4. Sigmoidoscopy or colonoscopy 5. Small bowel series= give the patient a chalky contrast to drink, they lay on table, and the x-ray watches the barium go down GI tract; if the patient has spams the barium may relax that so it can be considered diagnostic, and can cause spasm relief. ***Nursing history should include: symptoms, physical and psychosocial health history, family history, dietary history, and medication history.

Potential Complications Gerontological Considerations Therapeutic Management

Nursing Management

(1) 20 gram fiber, low fat diet (2) Increase water intake (3) Encourage diet diary (4) Avoid caffeine, alcohol, fried foods (5) Avoid gas forming foods (6) Stress reduction (7) Antispasmodics (8) Antidepressants (9) Eliminate common gas producing foods but going to be on a high fiber diet (10) Anticholinergic agents helpful to take before meals to alleviate the pain associated with the ingestion of food; they will decrease the cramping and help with constipation. (11) May also be on probiotics: like a bacteria we give in a pill that is used to help decrease bloating and gas. (Trying to enhance normal flora) ex. lactobacillus. Nursing Diagnoses 1. Constipation related to altered GI motility (decrease) 2. Diarrhea related to altered GI motility (increase) 3. Ineffective Coping related to effects of disorder on lifestyle 4. Altered Nurtition/Knowledge Deficit

DIVERTICULOSIS
Anatomy & Physiology 1. 2. 3. Diverticulum- Out pouching of intestinal mucosa at weak points in the bowel wall. Diverticulosis presence of multiple diverticula. Diverticulitis- inflammation. 1. Muscle tone of the intestinal wall is weakened and any pressure exerted within the colon results in saclike out pouchings (diverticulum) 2. Inflammation (diverticulitis) is caused by bacteria and fecal material trapped in the diverticula bacteria seep through the thin wall of the diverticula 3. Intestinal wall thickens and narrows. 4. *Common site=sigmoid colon (Etiology=Usually appears later in life; More common in Western society and less common in countries where diet consists of unprocessed grain; Chronic constipation, deficiency of dietary fiber, and stress may be contributing factors!) S/S of Diverticulosis: *Most are asymptomatic* 1. LLQ cramping pain relieved by passage of flatus or bowel movement 2. Alternating constipation and diarrhea 3. Rectal bleeding 4. Thin or pellet shaped stools S/S of DiverticuLITIS: 1. Left sided abdominal pain 2. Abdomen distended and tender 3. Palpable mass LLQ 5. Fever 6. Increased WBC and ESR A. Fecal occult blood positive B. Barium enema x-ray diverticula and thickened wall C. CBC increased WBC and ESR D. CT scan inflammation Diverticulosis Include: diverticulitis and hemorrhage. *DiverticuLITIS can lead to: abcess formation, perforation, peritonitis, bowel obstruction, fistula formation

Pathophysiology

Clinical Manifestations

Diagnostic Studies

Potential Complications

Gerontological Considerations Therapeutic Management

Nursing Management

Collaborative care/ Diverticulosis a. High fiber diet 20 grams/day b. Bulk agents c. Stool softeners d. Anticholinergics Collaborative Care/ DiverticuLITIS a. NPO progress as tolerated b. NG tube c. IV fluids d. Broad spectrum antibiotics e. Bedrest f. CBC g. Colon resection for obstruction or abscess. h. Temporary colostomy for perforation Nursing interventions 1. Measures to prevent constipation 2. Teach foods high in fiber 3. Avoid specific foods if not well tolerated 4. Avoid activities that increase intraabdominal pressure Teach to identify and reduce stress.

Anatomy & Physiology Pathophysiology

Clinical Manifestations

Diagnostic Studies

INFLAMMATORY BOWEL DISEASE **Ulcerative colitis** Ulcerative colitis=Inflammatory disorder of the large bowel; Usually chronic with periods of recurrence and remission; Most often diagnosed between ages 15 and 30 Etiology 1. Cause is unknown 2. Autoimmune disease 3. Heredity 4. Viral / bacterial infections 5. Emotional stress Pathophysiology 1. Inflammation of the mucous membrane of the colon and rectum 2. Ulcerations cause hypermotility and decreased absorption 3. Ulcerations begin at the rectum and ascend S/S of Ulcerative Colitis: (1) Abdominal tenderness and cramping (2) BLOODY, PURULENT, MUCOID STOOLS (3) TENESMUS (4) Anorexia / weight loss (5) Dehydration (6) Fatigue / Anemia Stool specimen positive for blood, mucous and pus Sigmoidoscopy ulcerations and hyperemia Barium enema ulcerations CBC decreased Hgb and Hct

Potential Complications

A. B. C. D.

E.
Gerontological Considerations Therapeutic Management Nursing Management

Perforation Toxic megacolon Colon cancer Extraintestinal complications: 1. arthritis 2. skin lesions and ulcers 3. mouth ulcers 4. uveitis= inflammation of the uvea of the eye Erythema Nodosum= redness of skin from fever & inflammation. *See Figure

INFLAMMATORY BOWEL DISEASE *Crohns Disease*

Chronic inflammatory disease that can affect any part of the GI tract

Anatomy & Physiology Pathophysiology

Most often affects the ileum and ascending colon Most often diagnosed age 10 to 30 Etiology Cause is unknown Autoimmune disease Heredity Viral / bacterial infection Pathophysiology Inflammation involving all layers of the bowel wall. Characterized by inflammation of segments of the GI tract skip lesions. Ulcerations are deep resulting in a cobblestone appearance of bowel wall Thickening and narrowing of bowel wall occur Granulomas present in 50% 1. Abdominal pain RLQ 2. Diarrhea 3. Borboygmus (means rumbling/gurgling noise that occurs from mvmts of fluid/gas in the intestines) 4. Nutritional deficiences 5. Weight loss 6. Fatigue 7. Fever 8. Dehydration (1) Colonoscopy skip areas of ulcerations (2) Barium enema cobblestoning, strictures, and fistulas (3) Small bowel follow-through (4) Positive fecal occult blood (5) Biopsy presence of granulomas (6) CBC decreased Hgb and Hct A. Strictures and obstruction B. Fistulas C. Intraabdominal abcess / perforation D. Anal abcess E. Extraintestinal problems

Clinical Manifestations

Diagnostic Studies

Potential Complications

Gerontological Considerations Therapeutic Management

Collaborative care DIET THERAPY: High protein, high calorie, low residue diet in small, frequent feedings MEDICATIONS: A. Aminosalicylates (5-ASA) (1) sulfasalazine (Azulfidine) (2) mesalamine (Pentasa) B. Corticosteroids (1) prednisone (2) hydrocortisone C. Immunosuppressive Rx (1) azathioprine (Imuran) (2) 6 mercaptopurine (6-MP) D. Biologic therapy (1) infliximab (Remicade) E. Anticholinergics F. Antidiarrheals G. Antibiotics H. Iron and vitamin supplements SURGICAL MANAGEMENT (ilieostomy & bowel ressection with anastomosis) (1) Poor response to conservative tx (2) Severe complications

Nursing Management

Nursing Diagnoses
(1) (2) (3) (4) (5) (6) Diarrhea r/t inflammed bowel; hypermotility Impaired Skin Integrity Altered Nutrition Anxiety Knowledge Deficit r/t disease process and tx Disturbed body image related to ostomy

COLORECTAL CANCER
Anatomy & Physiology Third most common cancer in US Occurs most often after age 50 5 year survival rate is 91% for early, localized colorectal cancer

Pathophysiology

Incidence of cancer by colon sites (See Figure)

Most colorectal cancers arise from adenomatous polyps Spread through intestinal wall into lymphatic system Usually spread to liver via portal vein Polyps Progresses slowly Remains localized for a long time (1) (2) (3) (4) (5)

Clinical Manifestations

Diagnostic Studies

Change in bowel habits Abdominal pain or cramps Rectal bleeding Tarry, ribbon-like, or bloody stools Sensation of incomplete evacuation (6) Iron deficiency anemia Diagnostic studies (1) Digital rectal exam (2) Fecal occult blood (3) Sigmoidoscopy (tissue biopsy) (4) Colonoscopy (5) CT scan of abdomen (6) Carcinoembryonic antigen (CEA) (7) CBC Medical Hx/Risk factors: 1. Over age 50 2. Family history of colorectal cancer 3. Adenomatous polyps 4. Inflammatory bowel disease 5. Diet high in animal fat and calories 6. Familial adenomatous polyposis

Potential Complications Gerontological Considerations Therapeutic Management

Collaborative care Surgery (1) Rt hemicolectomy (2) Lt hemicolectomy (3) Abdominal perineal resection with permanent colostomy Therapeutics Tx (1) Radiation therapy (2) Chemotherapy a. 5-FU (fluorouracil) b. Leucovorin c. CPT-11 d. Oxaliplatin (Eloxitan) e. Avastin f. Irinotecan (Camptosar)

Nursing Management

Nursing care
(1) Risk for Impaired Skin Integrity (2) Imbalanced Nutrition (3) Risk for Sexual Dysfunction (4) Ineffective Health Maintenance (5) Body Image Disturbance (6) Risk for Impaired Skin Integrity Teaching/PreventionHealth Promotion American Cancer Society Colon Screening Recommendations: (1) Annual digital rectal exam at age 50 (2) Annual fecal occult blood (3) Plus +Flexible sigmoidoscopy or double contrast barium enema q 5 year **********OR************* (4) Colonoscopy q 10 years

Classification

Dukes Classification System A B1 B2 C1 C2 D TNM (Tumor-Node-Metatasis) System Stage 0 No evidence of primary tumor Stage I Tumor invades submucosa Stage II Tumor invades subserosa Stage III Regional lymph node metastasis Stage IV Distant metastasis

OSTOMY SITES

Hartmann procedure

INTESTINAL OBSTRUCTION

Types of Obstruction

Hernias Are The Surgeons Vast Fair

Disorders of the Anus

(1) Adhesions: scar tissue that has built up (such as patients that have had several surgeries to one area) (2) Tumor (3) Volvulus: of the sigmoid colon; Note the edematous bowel. Counterclockwise twist of the bowel. This part of the bowel becomes necrotic and dies; surgery is needed. (4) Intussusception: invagination or shortening of the colon caused by movement of one segment of bowel into another; segments of the bowel has backed up into each other. Usually called telescoping. (5) Paralytic Ileus Hernia: (inguinal) the sac of the hernia is a continuation of the peritoneum of the abdomen. The hernial contents are intestine, omentum, or other abdominal contents that pass through the hernial opening into the hernial sac. *surgery to fix* Adhesions Tumor Stricture Volvulus Fair (1) Anorectal Abscess= caused by obstruction of an anal gland, resulting in retrograde infection. Those w/crohns disease have increased risk; contains a quantity of foul smelling pus and painful. (2) Anal Fistula= fibrous tract that extends into the anal canal from an opening beside the anus. Can occur due to infection-patient can develop systemic sepsis. This can repaired surgically. Patients with Crohns and ulcerative colitis tend to develop fistulas. (can occur in other places, ex. the lady that had a colon-vaginal fistula-had stool coming through her vagina) (3) Anal Fissure= much like an ulcer in the area (tear in the area thats pretty much localized)-very painful especially when they have a BM; makes the area edematous ; patient may take a warm sitz bath to relieve pain, take corticosteroids to decrease inflammation, stool softeners to prevent constipation which would make defecation more painful.

HEMORRHOIDS Pathophysiology Manifestations Risk Factors Potential Complications Diagnostic Studies Therapeutic Management
Dilated portions of veins in the anal canal. Common: found in 50% of patients over the age of 50. Classified as two types: external and internal hemorrhoids Itching and pain of the rectum; bright red bleeding with defecation

Collaborative Care (1) Surgery (Hemorrhoidectomy) done if the patient has severe external hemorrhoids (2) Surgical excision (3) Infrared photocoagulation, bipolar diathermy(electrical current that is used to cauterize the bleeding hemorrhoid) and laser therapy (4) Rubber-band ligation procedure (wrap area in rubber band, that part dies) (5) Cryosurgical hemorrhoids (freezing them off) Patient Care (1) High-residue diet (2) Bulk forming agents-Metamucil (3) Warm compresses (4) Sitz baths (5) Analgesic ointments and suppositories (6) Astringents-used to dry up or shrink the hemorrhoids (7) Bed rest

Nursing Management

Interventions 1. Encourage intake of at least 2 L water a day 2. Recommend high-fiber foods 3. Bulk laxatives, stool softeners, and topical medications 4. Promote urinary elimination 5. Hygiene and sitz baths 6. Monitor for complications 7. Teach self-care