BOWEL DIVERSION Flashcards
Anatomy of the small intestine
consists of the duodenum, jejunum and ileum.
- duodenum connects the stomach to the jejunum
- duodenum also contains the opening for common bile duct and pancreatic duct
- jejunum and ileum are closely fit in abdomen
anatomy of large intestine
the large intestine is the primary organ of bowel elimination and is divided into cecum, colon and rectum
- colon has 3 functions - absorption, secretion and elimination
fecal specimens (FOC V)
- Fobt - fecal occult blood testing - measures microscopic amounts of blood in stool
- O and p - stool for ova and parasite
- C and s- culture and sensitivity
- direct Visualization tests (endoscopy) - colonoscopy and sigmoidoscopy
- indirect Visualization X-ray with contrast - barium enema
what is rotavirus? what are the symptoms? how can you treat it?
Rotavirus is a viral infection that causes epidemic gastroenteritis and begins 24 hours after incubation
symptoms - mild - moderate fever, watery stools, vomiting
treatment - aimed at preventing dehydration
what is C. difficle? what are the symptoms? how can you treat it?
C. difficile is a bacterial infection caused due to antibiotic therapy.
symptoms - mild - moderate diarrhea, lower abdominal cramping
treatment - immediate discontinuation of antibiotic and in severe cases - eradication of c.difficle
when to collect stool specimen for someone who has C.difficle?
as soon as possible after onset of diarrhea occurs
What is IBS and how is it relieved?
Irritable bowel syndrome is a functional GI disorder
- symptoms include - abdominal pain, bloating, nausea, anorexia and diarrhea, altered bowel function
relieved by defecation and accompanied by a change in frequency or consistency of stool
What is inflammatory bowel disease? What are the types
- autoimmune disorder, chronic, reccurrent inflammation of intestinal tract. 2 main types
- Ulcerative colitis
- Crohn’s disease
Ulcerative colitis, signs and symptoms, pathophysiology
- characterized by inflammation, ulceration of colon and rectum. Starts at rectum moves up to sigmoid colon and spreads to colon
- can be acute or chrnoic
signs and symptoms - bloody diarrhea, abdominal cramping, tenesmus (sensation of needing to pass stool, accompanied by pain, crampoing and straining. Despite straining, little stool is passed. Recall urine with pain- dyuria??)
PATHO:
- multiple abscess (pocket of pus) develops in the intestinal gland and these abscesses break into submucosa, leaving ulcerations
- these ulceration destroy the muscosal epithelium, causing bleeding and diarrhea
- fluid and electrolyte loss
- protein loss
- psuedo polyps develop (i saw a picture of this and its gross)
crohn’s disease, signs and symptoms, pathophysiology
- chronic, nonspecific inflammtory bowel disorder of unknown origin
- can affect any part of the GI tract from mouth to anus
- most often seen in terminal ileum and colon
- inflammation involves all layers of bowel wall
- narrowing lumen
- may cause bowel obstruction
- microscopic leaks can allow bowel contents into peritoneal cavity (potential complication, indicates that fistula exist)
- 40% to 60% of recurrnace after surgery
SIGNS AND SYMPTOMS:
- depends on anatomic site but usually – diarrhea (no blood), colicky abdominal pain (cramp like pain), severe weight loss
PATHO:
- inflammation involves all layers of bowel wall
- skin lesion: segments of normal bowel occring between diseased portions
- ulcerations are deep and longitudinal and penetrate between islands of inflamed edematous mucosa - looks like a cobblestone
- microscopic leaks
- peritonitis may develop (redness and inflammation in the lining of abdomen)
- abscess of fistulous tract that communicate with other loops of bowel, skin, bladder, rectum or vagina may occur
white or clay coloured stools indicate ?
absence of bile pigment - obstructive jaundice
black or tarry coloured stools indicate ?
iron ingestion or upper gastrointestinal bleeding
pale with fat or frothy coloured stools indicate ?
malabsorption of fact
mucus or pus coloured stools indicate ?
colitis, excessive straining
bloody mucus coloured stools indicate ?
blood in feces, inflammation, infection and hemorrhoids
Consistency of feces:
liquid - diarrhea, reduced absorption
hard - constipation
NORMAL OR ABNORMAL??
a. frequency of stool more than 3 times a day
b. frequency of stool 2-3 times weekly
c. frequency of stool less than once a week
a. abnormal
b. normal
c. abnormal
what does a narrow, pencil shaped feces indicate?
anal or distal rectal carcinoma
diagnostic studies (Happy Birthday Sara)
- History and physical examination
- Blood studies:
- CBC - WBC - 4500 - 11,000, RBC - 4.5 million to 5.9 million for men, 4.1 million to 5.1 million for women, Hemoglobin - `14 to 17.5 gm/dL for men and 12.3 to 15.3 gm/dL for women
- serum electrolyte levels - sodium- 136 - 144 mmol/L, potassium - 3.7 to 5.1 mmol/L, calcium - 8.5 to 10.2 mg/dL
- serum protein levels - 60 to 83 g/L - Stool cultures:
- pus, occult blood and mucus
What is a colonoscopy?
endoscopic examination of the rectum, small bowel and colon that uses a long flexible tube (colonoscope) inserted into the rectum
when is colonscopy used?
- used to diagnose suspected pathologic conditions and is recommended for pts. who have had a change in bowel habits, occult or obvious blood in stool and/or abdominal pain
- also used as a surveillance tool for pts. who have had colorectal cancer or IBD or for those at risk for colon cancer
who performs anf endoscopy and how long is the whole thing?
- physician trained in GI endoscopy, performs this test in 30-60 minutes
- pt is heavily sedated and bowel must be clean and free of fecal material
when is a bowel prep ready? hint: based on colour
when it is light orange, mostly clear - almost ready
yellow, light, clear - ready anything other than this color is not ready
What is a sigmoidoscopy?
- examination of the interior of the sigmoid, colon and rectum
- preparation is similar to colonoscopy and light sedation is required
- takes about 15-20 minutes and is performed by physician trained in GI endoscopy
what is done before a sigmoidoscopy?
- bowel prep
- 2 fleet enemas are usually sufficient
- ingest only a light meal for breakfast the morning of the procedure
what is a bowel diversion?
- conditions that prevent the normal passage of feces through the rectum
types: - stoma - temporary or permanent artificial opening in abdominal wall
types of stoma
ileostomy - surgical opening in ileum
colostomy - surgical opening in colon
- end of intestine are brought through abdominal wall to create stoma
consistency of stool for an ileostomy
bypasses the entire large intestine - stools are frequent and liquid
consistency of stool for a colostomy of transverse colon
solid, formed stool
types of colostomies
- loop colostomy
- double barrel colostomy
- end colostomy
how is an ostomy surgery done
- bowel is brought through an opening in the abdominal wall and edges of the bowel are sutured to surrounding skin exposing the inner lining of the bowel called stoma
- bowel function will occur through stoma
- may be permanent/temporary depending on underlying reason for surgery
what is a loop colostomy?
- loop stoma is created by mobilizing the side of intestine through an opening in abdominal wall
- loop colostomies are temporarily large constructed in transverse colon
- surgeon pulls a loop of bowel onto abdomen and loop ostomy has 2 openings - proximal end that drains stool and the distal end that drains mucus
- temporary/supporting rod may be placed under the stoma to prevent stoma retraction
what is end colostomy
- attatched one end of the colon or ileum to an opening in the abdominal wall - often in sigmoid colon
- an end ileostomy is often in the last part of the ileum and the rest of the colon may be completely removed
- end colostomies are a result of treament for colorectal cancer
double barrel colostomy
- bowel is surgically severed and the two ends are brought into abdomen
- so you have two stomas that can be positioned side by side or with some distance apart (opposed to loop but same functions of draining stool and mucus)
what is a kock continent ileostomy
- created using small intestine to create a pouch (pouch is formed inside abdominal cavity behinf the stoma that collects the fecal material)
- thin tube inseted into stoma to drain content
- stoma is shaped into a valve to prevent fluid from leaking into patients abdomen
Who pouches ostomies?
an enterostomal therapist - trained to care for would and ostomy management
what are some skin barriers for ostomies?
wafers, paste, powders and liquid film applied to skin around stoma
one piece pouch system vs two piece pouch system
one piece pouch - wafer skin barriers are permanently attatched to ostomy pouch
two piece pouch - pouch can be detatched from skin barrier for emptying or changing
Pouching an ostomy
- observe skin barrier and pouch for leakage and length of time in place. Depending on the type of pouch you may need to remove to fully observe stoma
- observe stoma - colour, swelling, trauma and healing and type of stoma (flush or bud like?)
3.Measure stoma at each pouching change - opening of appliance should be no greater than 2mm larger than the stoma - Observe abdominal incision (if present)
- Observe effluent from stoma and record intake and output - empty if puch is more than one-third to one-half full and ask pt bout tenderness. Pouch must be emptied as the weight may disrupt adhesive on skin
- Assess abdomen for best type of pouching to use (consider contour and peristomal plane, presence of scars, incision, location and type of stoma)
- keep pouch loosely attactched to collect any drainage while changing
- position pt. either standing or semi-reclining and draped
- completely remove used pouch and skin barrier by gently pushin the skin away from barrier. An adhesice remover can be used here. Clean peristomal skin gently with tap water using gauze pads or a clean washcloth, do not scrub skin, dry with gauze/towel and measure stoma for the correct size
- use ostomy guide to select appropriate pouch. Prepare by removing backing from barrier and adhesive. For an ileostomy, apply a thin circle of barrier paste around the opening in the pouch and let dry
- barrier paste facilitates seal and protects skin. Apply barrier paste and pouch, if creases occur, use barrier paste to fill in and let dry fo 1-2 minutes
- for one piece pouching:
- use skin sealant wipes on skin under adhesive skin barrier pouch and allow to dry. Hold pouch by barrier and centre it over stoma, and press down gently, bottom pouch should face knee
- for 2 piece
- apply the flange (adhesive w barrier) the same as one piece and snap on pounch and maintain finger pressure - gently tug pouch in downward direction - for both pouching system
- apply nonallergenic paper tape around pectin skin barrier in a pictureframe method (half the tape on skin barrier and half on skin)
- fold bottom of drainage open ended pouch up and close using a closure device such as a clamp
normal findings for colour of stoma
moist and reddish pink
what happens when the opening around the appliance is too large or too small?
too large - can permit fecal drainage to ooze from under the appliance, causing skin irritation
too small - can cause appliance to cut stoma
what happens if the effluent comes in contact with the sensitive peristomal skin?
risk of skin breakdown increases
how should stoma be placed to have an adequate seal?
- the stoma must be placed within the abdominal rectus muscle, away from abdominal creases and folds, away from bony structure and surrounded by atleast 5cm of smooth surface on all sides
If the skin around the stoma is discoloured, weeping, itchy, or sore. what can you do?
refer the patient to an ostomy specialist
when are pouches and skin barriers changed?
- when there is a leak
- before or after shower
- when pt wants
- before a meal - avoids increased peristalsis and chance of evacuation during pouch change
What do you do If the patient has a large volume of liquid stool from an ileostomy
consider using a high-output pouch that will contain the volume of effluent and reduce the frequency of pouch emptying
If the patient has a surgical incision near the stoma, what do you do with the skin barrier
the skin barrier may need to be trimmed to fit.
how often do you change a one-piece/two-piece pouch system
3-7 days unless it leaks
unexpected outcomes for a stoma
damage of peristomal skin
- necrosis of stoma
normal location of stoma
should be flush with skin or slightly above skin level
pale stoma indicates
anemia
nercotic stoma indicates
nercotic tissue - inform physician
NORMAL OR ABNORMAL? explain why if abnormal
a. small amount of stoma bleeding immediately post operation
b. bleeding into pouch
c. small amount of bleeding while cleaning stoma
d. mild to moderate swelling until 2-3 weeks post op
e. moderate to severe swelling
f. mucous and air in stool post op
a. NORMAL
b.ABNORMAL - concerning and implies coagulation problem and GI blees
c.NORMAL
d.NORMAL
e. ABNORMAL- may obstruct stoma
f. NORMAL - takes a couple days for peristalsis to return
how to precent peristoma erythema post op?
cleaning and skin prep
foods that cause gas
beans, onions, cabbage, beer, cheese, carbonated beverage
foods that increase odor
eggs, garlic, onions, fish, asparagus, cabbage, broccoli, alcohol.
foods that could cause diarrhea
spinach, green beans, coffee, spicy foods, raw fruits, alcohol.
foods that could cause obstruction
nuts, raisins, corn, raw vegetables
foods that could cause constipation
cheese, rice, apples, bananas, tapioca
Prolapse stoma
A prolapsed stoma is a stoma that develops a length longer than what was created at the time of surgery. The prolapse is created by the outward telescoping of the bowel. The length of the prolapse can vary.
protruding stoma
Stoma protrudes above level of the skin by approximately 2cm
retraction of stoma
Stoma protrudes above level of the skin by approximately 2cm
are these complication of stoma? yes or no
a. prolapse
b. flush
c. bowel obstruction
d. High output
e. excoriated surrounding skin
a. yes
b. no
c. yes
d. yes
e. yes
