Chapter 59 Flashcards
Irritable bowel syndrome is sometimes called….
Spastic colon
Mucous colon
Nervous colon
A functional GI disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating.
IBS (Irritable Bowel Syndrome)
The most common digestive disorder seen in clinical practice
IBS
1 in 5 people in the US
Types of IBS: (4)
IBS-D (diarrhea)
IBS-C (constipation)
IBS-M (mix)
IBS-A (alternating)
Symptoms of IBS usually appear in ____________ and continue throughout the lifetime. And _________ are 2x more likely to get it
young adulthood, women
Foods that irritate IBS include…
Caffeine
Carbonation
Dairy
Mental problems associated with IBS include…
Anxiety and depression
*usually meet the criteria for at least 1 mental health disorder
Which of these are signs and symptoms of IBS?
- Vomiting
- Flatulence
- Abdominal distention
- Weight loss
- Presence of mucus in stool
- Fatigue
2, 3, 5, 6
Which of these are signs and symptoms for IBS?
- Abdominal pain
- Sense of incomplete evacuation of stool
- Nausea
- Epigastric pain
- Melena
- Electrolyte imbalances
1, 2, 3
One of the most common symptoms of IBS is pain in the _______ and nausea associated with ____________________.
LLQ, mealtime and defecation
True or False: Patients with IBS are usually underweight
False- usually a stable weight with in-range fluid balances and lab values
IBS is usually diagnosed by ______________ but sometimes a ____________ will be used.
Signs and symptoms/history, hydrogen breath test (presence of hydrogen on exhalation is positive result)
Teaching for the hydrogen breath test:
- NPO 12 hours before (may have water)
- Patient blows into hydrogen analyzer, ingests small amounts of sugar, and breath samples are taken every 15minutes for an hour or longer. Lactose may be ingested to test for intolerance and lactulose may be given.
Foods to avoid for patients with IBS:
Caffeine, alcohol, eggs, wheat, beverages with sorbitol and fructose, milk/dairy, raw fruits, grains
The patient should ingest _______ of fiber each day to help produce bulky, soft stools and establish regular bowel habits. Patients should also be taught to…
30-40g, Chew food slowly
For patients with IBS-C _________________, such as __________ may be taken at mealtime with a glass of water to prevent dry, hard, or liquid stools. Amitiza is anew oral drug for women with IBS-C that increases intestinal chloride.
bulk-forming laxatives
psyllium (Metamucil)
IBS-D may be treated with ________ and __________. Lotronex may be used as a last resort and patients must agree to report symptoms of colitis or constipation promptly as they could lead to life-threatening bowel complications.
loperamide (Imodium)
psyllium (Metamucil) a bulk forming agent
Pain associated with IBS may be treated with ________. The pain is usually ___________and they should take the drugs _________________.
amitriptyline (Elavil), postprandial (after eating), 30-45 minutes before meals
Alternative/Complimentary therapies for IBS include….
Probiotics Peppermint oil Acupuncture moxibustion (Acu-Moxa) Counseling Stress-management Regular exercise
A weakness in the abdominal muscle wall through which a segment of the bowel or other abdominal structure protrudes.
Hernia
A hernia that protrudes through the inguinal ring. Can become large in males and descend into the scrotum
Indirect inguinal hernia
A hernia that passes through a weak point in the abdominal wall (through an area of muscle weakness).
Direct inguinal hernia
A hernia that protrudes through the femoral ring. May pull the peritoneum and urinary bladder into the sac.
Femoral hernia
A hernia that is congenital or acquired. Congenital appear in infancy and acquired result from increased abdominal pressure. commonly seen in obese patients.
Umbilical hernia
Hernia that occurs at the site of a previous surgical incision that is inadequately healed (infection, inadequate nutrition, obesity).
Incisional/Ventral hernia
A hernia is ______ when the contents of the sac can be placed back into the abdominal cavity with gentle pressure, it is _________ is it cannot.
Reducible, irreducible
*****Any hernia that is irreducible requires immediate surgical eval.
When the blood supply to the herniated segment of the bowel is cut off by pressure from the hernial ring.
Strangulation
Signs and symptoms of strangulation in a hernia:
- Nausea
- bradycardia
- pain
- decreased LOC
- Fever
- distention
1, 3, 5, 6
Signs and symptoms of strangulation of a hernia:
- Vomiting
- Coughing
- Tissue ischemia
- Tachycardia
- Hypotension
1, 3, 4
Two most important elements in the development of a hernia
- Congenital or acquired muscle weakness
- Increased abdominal pressure
The most common type of hernia is the __________, the _________ hernia occurs most often in older adults, _______ and ________ hernias are most common in obese or pregnant patients.
Indirect inguinal (most common in men), direct, umbilical and femoral
Absent bowel sounds may indicate _______ and ________.
Obstruction, strangulation
**Medical emergency
To palpate the inguinal hernia, the provider…
Inserts a finger and notes changes when the patient coughs
A hernia is never forcibly reduced because…
It could cause strangulated intestine to rupture
Part of hernia assessment includes inspecting the abdomen when the patient is _______________, a hernia that is reducible may disappear when ______________, APRN asks the patient to perform ____________ to observe for ___________.
lying and standing, lying flat, Valsalva maneuver, bulging
A pad made with firm material, held in place over the hernia with a belt to keep the abdominal contents from protruding into the hernial sac.
Truss
- Applied only after the surgeon has reduced the hernia
- Teach to assess the skin under the truss daily and protect it with a light layer of powder
________ is the treatment of choice for the inguinal hernia.
Surgery
Preoperative for the hernia surgery:
NPO for surgeon specified hours
Arrange for transport
_________ is the surgery of choice for a hernia and _______ is when the surgeon reinforces the weakened outside abdominal muscle wall with a mesh patch.
MIIHR (minimally invasive inguinal hernia repair OR herniorrhapy)
Hernioplasty
True or False: The patient with have only soreness and discomfort rather than acute pain after a MIIHR.
True- Any acute pain should be reported
True or False: The patient should be taught to turn, cough, and deep-breath following MIIHR
FALSE- coughing is contraindicated. DEEP BREATHING AND AMBULATION ARE PROMOTED for lung expansion
Postoperative care the the MIIHR
- Allow patient to elevate scrotum and use ice
- Promote deep breathing and ambulation for lung expansion
- Encourage patient to stand while voiding
- Report urine output <30mL/hour
- Fluid intake of at least 1500-2500 mL/day to prevent dehydration and maintain urinary function
- Intermittent catheterization for patients unable to void
- Keep wound clean and dry with antibacterial soap and water. Shower after a few days
Most CRCs are ____________, which are tumors that arise from the glandular epithelial tissue of the colon.
Adenocarcinoas
Most CRCs are in the _______ region
Rectosigmoid
*25% sigmoid, 30% rectal
The _______ is the most frequent site of metastasis for CRC.
Liver
Complications of CRC:
- Obstruction
- Perforation
- Peritonitis
- Abscess formation
- Fistula formation (into urinary bladder or vagina)
- Bleeding
Risk factors for CRC:
- Over 50years old
- Genetics (FAP)
- Crohn’s disease
- Ulcerative colitis
- Polyps
- Smoking and drinking
- Increased body fat, decreased physical inactivity
The diet most associated with CRC is…
High fat (RED MEAT), high carb, low fiber, increased bacteria (from high-fat)
Recommendations for CRC screening:
FOBT (w/ sigmoidoscopy)- Every 5 years
Double-contrast barium-enema- Every 5 years
Colonoscopy- Every 10 years
The most common signs of CRC are _________, _____, and ______________.
Anemia, rectal bleeding, change in stool consistency and shape
Which of these are signs of ADVANCED CRC?
- Nausea
- Abdominal fullness
- Visible peristalsis
- Fatigue
- Vague abdominal pain
- Unintentional weight loss
2, 4, 5, 6
Tumors in the transverse or descending colon result in symptoms of….
Obstruction (tumor blocks passage of stool)
Gas pains/cramping
Incomplete evacuation
Tumors of the rectosigmoid colon are associated with….
Hematochezia (passage of red blood in the stool)
Straining to pass stool
Narrowing of stool
Dull pain
Right sided tumors present with….
Dark/mahogany colored blood
Mass palapated in RLQ
Visible peristaltic waves
High-pitchd/tinkling bowel sounds
Lab values for CRC indicate…
- Decreased Hb and Hct (first signs)
- Liver test elevation (if metastisis)
- Positive FOBT (patient should avoid vit. C, red meat, and anti-inflammatories before testing)
- Elevated CEA (above 5mcg/L)
_________ is the definitive test for CRC.
Colonoscopy with biopsy.
Priority problems for the patient with CRC:
- Potential for metastasis
- Grieving
_______ is the primary means used to control CRC.
Surgical resection
Stage of CRC that involves any level of tumor invasion and up to 4 regional lymph nodes
Stage 3
Stage of CRC that involves tumor invading up to other organs or perforates peritoneum.
Stage 2
CRC tumor stage where tumor invades up to the muscular layer.
Stage 1
CRC tumor stage where tumor invades any level, many lymph nodes are affected with distant metastases
Stage 4
Preoperative interventions for CRC removal:
- Explain anatomical and physical changes/ location and number of incisions and drains
- If colostomy is planned, teach patient general principles and bring in specialist for placement
- Discuss possible sexual dysfunction and urinary incontinence
- Bowel prep of GOLYTELY, enemas, laxatives or whole-gut lavage
- 1 dose antibiotics
- NGT may be placed for decompression after surgery
- Clear liquid diet 1-2days before
____________ is the best method of ensuring removal of CRC.
Surgical removal with margins free of disease
A ___________ removes the tumor and regional lymph nodes with reanastamosis, a ________ removes the entire colon and ________________ is performed when rectal tumors are present and involves removal of the sigmoid colon, rectum , and anus through abdominal and perineal incisions.
Colon resection, colectomy, abdominoperineal (AP) resection
For the AP surgery, there is a risk of….
Postoperative sexual dysfunction and Urinary incontinence
A ________ is made by bringing a loop of the colon to the skin surface, severing and everting the anterior wall, and suturing it to the abdominal cavity.
Loop stoma
** ROD WILL BE PLACED- TAKE SPECIAL CARE DO NOT DISPLACE POST-OP
A ___________ is often constructed, most often in the descending or sigmoid colon when a colostomy is intended to be permanent, but may also be sewn to the abdominal cavity for future reattachment.
End stoma
A _____________ is the least common colostomy created by dividng the bowel and bringing both the proximal and distal portion to the abdomen surface. The _________ stoma is functioning and eliminates stool, the ______ stoma is nonfunctioning but may secrete mucous (Mucous fistula).
Double-barrel, proximal, distal
Post operative care for CRC removal and AP resection:
- NGT remains until peristalsis returns, then liquid diet slowly progressed as tolerated
- IV PCA for first 24-36 hours
- Avoid driving for 4-6 weeks until incision heals(conventional)
- Resume activities in 1-2 weeks (MIS)
- Teach patient to avoid heavy lifting and straining on defecation
- Two JP drains for AP resection for several days (drainage should be serosanguinous for 1-2 months, complete healing after 6-8 months)
- Phantom sensations in rectal area may require antipruritic drugs (benzocaine) and sitz baths
The stoma should be _________, and protrude ______ from the abdominal wall. It may be sightly edematous with a small amount of bleeding postoperatively. It should start functioning in ______ days postoperatively.
reddish pink and moist, 3/4in (1/2-1in), 2-4
For the stoma, ________ should be reported as signs of ischemia, ________ as signs of necrosis, as well as ________ and __________. Peristomal skin should be ___________. Notify doctor immediately if any of these occur.
Pale, blue, flaccid
Dark, black, brown, firm
Unusual bleeding
Mucocutaneous separation (Breakdown of the suture line)
Intact, smooth, without redness or excoriation
Effluent from the ascending colon will be ___________, from the transverse will be _____________, from the descending _______________, and from an ileostomy ______________.
Watery, liquid
Thin gelatin to Thick and pasty
Like regular stool, solid
Watery, dark green, lots of enzymes
A ________ is constructed when the whole colon is removed and the end of the small intestine.
Ileostomy
** Ensure no leakage as it easily irritates skin (ensure bag fits properly and use skin barrier cream)
The colostomy pouch should be change every ____________, the skin barrier should be changed every _____________. Leave _____ around the wafer when cutting to size so that it does not touch the stoma. Place on dry, clean skin and always use a ____________.
3-7, 5-7, 1/16”-1/8”, skin barrier cream
Signs and symptoms of intestinal obstruction and perforation after colostomy include:
- Cramping
- Abdominal pain
- Nausea
- Vomiting
- Should also report fever or sudden onset of pain and swelling
The stoma will shrink within ______ weeks after surgery and the stoma should be measured once ______ and if the patient __________.
6-8, weekly, loses/gains weight
True or False: The patient should use a moisturizing soap and water to clean the stoma area before applying a device.
FALSE_ these interfere with adhesion of the appliance
Foods to be avoided because they produce gas are….. These behaviors produce gas…and foods that prevent gas are…. Foods that contribute to odor are… while foods that prevent odor are… The patient should never place _______ in the pouch.
- Broccoli, beans, spicy foods, onions, brussels sprouts, cabbage, cauliflower, cucumbers, mushrooms, peas
- Chewing gum, smoking, drinking beer, skipping meals
- Crackers, toast, yogurt
- Asparagus, broccoli, cabbage, turnips, eggs, fish, garlic
- Buttermilk, cranberry juice, parsley, yogurt
- Aspirin tablet
In _____________ obstruction, the bowel is physically blocked with a problem from outside the intestine, in the bowel wall, or in the intestinal lumen. IN _________ obstruction, peristalsis has decreased or is absent. It is also known as _________.
Mechanical, Non-mechanical, Paralytic/adynamic ileus
Complications of obstruction include:
- Electrolyte imbalances
- Hypovolemic shock
- Renal insufficiency (from severe hypovolemic shock)
- Strangulation
_____________ is an obstruction with compromised blood flow and a __________ is a blockage in two different areas. Both of these greatly increase the risk for _______.
Strangulated, closed-loop obstruction, Peritonitis (and septic shock)
Causes for obstruction in the elderly (65+) include:
- Diverticulitis
- Tumors
- Fecal impaction
__________ is the electrolyte imbalance that predisposes the patient to paralytic ileus the most.
Hypokalemia
Most obstructions occur in the ___________.
Small intestine
________________ may indicate perforation of obstruction and should be reported immediately. The patient should be ________________ when obstruction is suspected. Temperature of over 100 with sustained elevation in pulse can indicate ___________ or ____________.
Severe pain that stops or changes to tenderness, NPO, strangulation or peritonitis.
Identify a symptoms as Small or Large bowel obstruction:
- Intermittent lower abdominal cramping
- Obstipation
- Ribbon-like stools
- Metabolic alkalosis
- Profuse foul-smelling vomit
- Severe fluid and electrolyte balances
- Intermittent lower abdominal cramping: LARGE
- Obstipation: BOTH
- Ribbon-like stools: LARGE
- Metabolic Alkalosis: SMALL
- Nausea and profuse vomiting: SMALL
- Severe fluid and electrolyte imbalances: SMALL
Identify a symptoms as Small or Large bowel obstruction:
- Borborygmi
- Abdominal distention
- Visible Peristaltic waves
- Metabolic Acidosis
- Colicky abdominal pain
- Cramping
- Borborygmi: BOTH
- Abdominal distention: BOTH (in separate areas)
- Visible peristaltic wave: BOTH
- Metabolic Acidosis (LARGE)
- Colicky abdominal pain (LARGE)
- Cramping (SMALL)
Non-mechanical obstruction signs and symptoms are:
- Constant diffuse discomfort
- Abdominal distention
- Decreased-absent bowel sounds
- Vomiting of gastric content *NOT foul
- Possible obstipation
Strangulation is present if pain becomes…. and the presence of….. may signal a closed-loop, strangulating small-bowel obstruction.
More localized and steady, palpable abdominal mass
Strangulated obstruction usually shows high _______ and ______ levels
WBC, amylase
Hb, Hct, creatnine, and BUN are elevated with obstruction because of ___________. While sodium, chloride, and potassium are reduced.
Dehydration
Nonsurgical management is the treatment of choice for ___________, and surgical management is the treatment of choice for ____________.
Paralytic ileus/non-mechanical obstruction
Complete (sometimes incomplete) mechanical obstruction
*Strangulated ALWAYS requires surgery
Management of the paralytic ileus includes:
- NPO
- NGT to decompress (with suction: salem: low/continuous, Levin-low/intermittent)
- Assess for flatus/stool to indicate peristalsis has returned
- Tell patient to report nausea
- Assess for signs of plugged and displaced tube (nausea, vomiting, decreased/stasis of output, increased distention)
A priority for all patients with intestinal obstruction is….
IV FLUID REPLACEMENT AND MANAGEMENT
*because NPO and electrolytes are lost through NGT and vomiting
True or False: Opioid analgesics are used to help with the pain of intestinal obstruction
FALSE: should be withheld so that clinical manifestations of perforation or peritonitis are not masked. ALWAYS GIVE RATIONALE TO PATIENT.
Postoperative care for the patient with intestinal obstruction:
- NGT until peristalsis returns (discontinued by clamping, checking residual to assess peristalsis)
- Clear liquids while NGT is disconnected from suction to see how tolerated. (If vomit, suction is resumed)
- Instruct patient to report nausea, vomiting, and constipation (Recurrent obstruction Not common in paralytic ileus)
- Oral opioid analgesics (Tylox, Percocet, Endocet) with laxative (Docusate with Senna)
