Gastrointestinal Case Studies Flashcards
Over 50 years of age
Long term smoking - sig
Other risk factors: genetics (family history - may get screened earlier), high fat diet (lot fast food), low activity, high ETOH (alchol) intake, hx of polyps, crohns, ulcerative colitis, H pylori, HPV, obesity
What risk factors did this client have for colorectal cancer?
Rectal bleeding
Anemia
Change in stool consistency or shape - obstruction/tumor can change shape or can have change in consistency
What are the most common signs/symptoms of colorectal cancer?
CBC may show decreased H/H - thinking about anemia
Fecal occult blood testing (positive)
Carcinoembryonic antigen (CEA) may be elevated - not specific to colorectal cancer; tell might have cancer
CT scan
Colonoscopy: definitive test for the diagnosis
Liver function tests: may be elevated if metastasis to the liver has occurred
What types of diagnostic tests would be appropriate to gather more information about Mr. Moore’s condition and what might the laboratory tests show if he has colorectal cancer?
Screening at age 50 - colonoscopy
Fecal occult blood testing and colonoscopy every 10 years
Diet – decrease fat and refined carbohydrates and increase fiber, eat baked or broiled foods, not fried food
Avoid smoking and heavy alcohol consumption
Increase physical activity
What health promotion and maintenance interventions should patients practice to avoid a colorectal cancer diagnosis?
Radiation
Chemotherapy
Surgery
Colon cancer treatment
Based on size of tumor, location, metastasis
Colon resection
Colectomy
Abdominoperineal (AP) resection
Surgery - Colon cancer treatment
Remove tumor and any lymph nodes
Colon resection
Remove colon with a colostomy or ileostomy
Colectomy
Remove sigmoid colon, rectum and anus
Abdominoperineal (AP) resection
The nurse is teaching a patient with colorectal cancer how to care for a newly created colostomy. Which patient statement reflects a correct understanding of the necessary self-management skills?
A. I will have my spouse change the bag for me
B. If I have leakage, I should reinforce the barrier with tape
C. A dark purple stoma is normal and would not concern me
D. I will apply nonalcoholic skin sealant around the stoma and allow it to dry prior to applying the bag
Answer: D
Alcohol: burning, dry it out, irriation
A clear ostomy pouch will be in place to allow for visualization of stoma
Assess the color and integrity of the stoma frequently
Should start functioning in 2-3 days
Stool consistency depends on where in the colon the stoma was placed:
Bag should be emptied when ⅓ to ½ full to prevent pulling
Entire Pouch (appliance) should be changed every 3-7 days
Lots of education needed - permanent/temp
Colostomy care
Many different types, will depend on where the stoma is located, how active the patient, size and curve of abdomen
A clear ostomy pouch will be in place to allow for visualization of stoma
Healthy stoma should be reddish or pink and moist and protrude about ¾ inch (2 cm) from the abdominal wall
May be slightly edematous and have a small amount of bleeding initially
Assess the color and integrity of the stoma frequently
Liquid: ascending colon or if has an ileostomy
Pasty: tranverse colon
More solid: descending colon and sigmoid
Stool consistency depends on where in the colon the stoma was placed:
Check surrounding skin, keep good seal, good assessment of stoma
Entire Pouch (appliance) should be changed every 3-7 days
Collaborate with CWON for education and ongoing stoma and pouch care
Good edu - wound care to know educated good as well
Lots of education needed - permanent/temp
Bowel is physically blocked by problems outside the intestine, in the bowel wall or within intestinal lumen
Ex. adhesions (outside) Crohn’s (within bowel walls), tumors (within intestinal lumen)
Most common causes in patients over 65 is diverticulitis, tumors, or fecal impaction
Describe the causes of mechanical intestinal obstructions.
Paralytic ileus
peristalsis is decreased or absent
Most common cause handling of the intestines during abdominal surgery
Describe the causes of nonmechanical intestinal obstructions.
Abdominal discomfort or pain
Visible peristaltic waves when observing abd
Upper or epigastric abdominal distention
Nausea and early on
Profuse vomiting
Obstipation - severe constipation; no gas/stools
Small bowel obstruction
Intermittent lower abdominal cramping
Lower abdominal distention
Minimal or no vomiting
Obstipation or ribbon-like stools - going around obstruction
No major fluid and electrolyte imbalances - not vomiting; more absorption
High pitched bowel sounds transitioning to absent bowel sounds
Large bowel obstruction
NPO
NGT including suction - lots output quickly and improves quickly esp if small bowel obstruction
Assess and record passage of flatus and character of bowel movements
Monitor VS
IVF - IV fluids; not want dehydration since vomiting
Weight
I/O
Assess and treat pain
Monitor for complications
What interventions are appropriate for Mrs. Jump’s SBO?
Indicative that peristalsis has returned
Assess and record passage of flatus and character of bowel movements
Monitor electrolyte imbalances
I/O
Cautiously use opioids to treat pain secondary to slowing movement on GI tract - further causing constipation - depends on how bad pain; do other things if possible
Assess and treat pain
Bowel perforation
Ischemic bowel
Peritonitis - inflammation of membrane lining of abdominal well of intestines
Monitor for complications
Creates widespread inflammation of mainly the rectum and rectosigmoid colon but can extend to the entire colon when the disease is extensive - all layers of bowel
Etiology: unknown; but some genetic components, immunologic, and environmental factors likely contribute to disease
Ulcerative colitis
In addition to the report of diarrhea, what other clinical manifestation might the client report?
A. Poor skin turgor
B. Confusion
C. Increased weight
D. Clay colored stool
Answer: A
Dehydration - lot of stool so at risk for dehydration; look at skin turgor and other s/s of dehydration
10-20 stools
What clinical manifestations of ulcerative colitis make Molly at higher risk for decreased oxygenation and fatigue?
A. Bloody stools
B. Fever
C. Electrolyte abnormalities
D. Elevated inflammatory markers
Answer: A
Decreased Hgb so higher risk for decreased in oxygenation and when anemic would be tired
10-20 liquid/loose, bloody stools per day - decreased Hgb
Stool may contain mucus
Tenesmus (an unpleasant and urgent sensation to defecate)
Lower abdominal colicky pain relieved with defecation
Malaise
Anorexia
Anemia
Dehydration - poor skin turgor
Fatigue with anemia - decreased Hgb
Fever
Weight loss - due to stools
Anemia
Increased WBC
Elevated C-reactive protein and ESR - indicate inflammation
Decreased electrolytes - given number stools
Molly does not have any other GI symptoms at this time. What are some other symptoms she might experience? - Clinical manifestations:
Molly is scheduled for a flexible sigmoidoscopy and barium enema. How should the nurse explain the flexible sigmoidoscopy?
A. X-ray is used to visualize the large intestine after barium is instilled
B. Visual exam using a fiberoptic scope of the upper GI tract
C. Visual exam using a fiberoptic scope of the rectum and sigmoid colon
D. A digital rectal exam after an enema
Answer: C
Clear liquids typically the day before and sometime NPO the day of the procedure
One to two enemas the day of the procedure
Does not require total bowel cleanse as required for a colonoscopy
What type of prep is required for a sigmoidoscopy?
Increase fluids to facilitate the excretion of the barium from the colon - get barium out of colon: PO/IV
What post op procedure instructions should the nurse include post barium enema?
Which clinical manifestation would be concerning to the nurse following the flexible sigmoidoscopy?
A. Temperature
B. Rigid abdomen
C. Decreased urine output
D. Inelastic skin turgor
Answer: B
Bowel perforation and possible peritonitis
What complication does this assess for?
Abdominal guarding with pain, boardlike abdomen when palpating, strong pain; feel very hard
What are other signs and symptoms?
Decrease inflammation
Prednisone:
Decrease inflammation
Sulfasalazine:
Suppress immune system so does not overreact
Azathioprine:
Immunomoduators are given to suppress the immune system
Glucocorticoids are used during exacerbation to decrease inflammation
Aminosalicylates are used to decrease inflammation
Antidiarrheals are given cautiously - lot stools but not want increased pressure on large intestine and enlarge colon
Drug therapy: - Ulcerative colitis: treatment:
NPO
TPN - nutrition through central line; depending on how long be NPO
Avoid caffeine, alcohol, raw vegetables, high fiber foods (decrease peristalsis), lactose containing foods
Nutrition therapy: - Ulcerative colitis: treatment:
Can reduce intestinal activity, provide comfort, and promote healing
Restrict activity - Ulcerative colitis: treatment:
Hbg and Hct
Electrolyte values
VS
Monitor for GI bleeding - Ulcerative colitis: treatment:
Removal of colon if other meds or other treatment not effective
Surgery may be required if medical therapies alone are not effective - Ulcerative colitis: treatment:
Begins in rectum and proceeds toward the cecum
Location - Ulcerative colitis
Unknown
Etiology - Ulcerative colitis
15-25 and 55-65
Age of incident - Ulcerative colitis
10-20 liquid, bloody
stools per day - Ulcerative colitis
Hemorrhage
Nutritional deficiencies - all bowel movement
Complications - Ulcerative colitis
Infrequent
Need for surgery - Ulcerative colitis
Most often in terminal ileumm can also involve colon with patchy involvement throughout all layers of bowel - lots surgeries to help; patchy areas; skipped lesions
Location - Crohn’s disease
Unknown
Etiology - Crohn’s disease
15-40
Age of incident - Crohn’s disease
5-6 soft, loose nonbloody
stools per day - Crohn’s disease
Fistualas (common)
Malabsorption and nutritional deficiencies - all bowel movement
Obstructions due to inflammation and scarring
Complicatins - Crohn’s disease
Frequent
Need for surgery - Crohn’s disease
Chronic inflammatory disease of the small intestine (most often), the colon, or both
Presents as inflammation that causes a thickened bowel wall
Etiology: unknown, but may include genetic, immune, and environmental factors
Clinical Manifestations:
Lab findings:
Diagnostic testing:
Treatment
Crohn’s disease
Noted by “skip” lesions
Involves all the layers of the intestinal wall
Presents as inflammation that causes a thickened bowel wall - Crohn’s disease
5-6 soft, loose stools per day, non-bloody
Abdominal pain
Low-grade fever
Weight loss
Clinical Manifestations: - Crohn’s disease
Anemia
Decreased folic acid and Vitamin B12
Decreased albumin levels
Elevated C-reactive protein and ESR - indicates inflammation
Lab findings: - Crohn’s disease
X-ray: shows narrowing, ulcerations and strictures
Magnetic resonance enterography (MRE): determine bowel activity/motility
Abdominal ultrasound
Abdominal computerized tomography
Colonoscopy
GI bleeding scan
Diagnostic testing: - Crohn’s disease
Immunomodulators are given to suppress the immune system
Glucocorticoids are used during exacerbation to decrease inflammation
Aminosalicylates are used to decrease inflammation
Antidiarrheals are given cautiously - not want enlarge colon
Treatment - Drug therapy: - Crohn’s disease
NPO
TPN
Nutritional supplements
Nutrition therapy - Drug therapy: - Crohn’s disease
Treatment includes nutrition and electrolyte therapy, skin care, and prevention of infection - skin involved get wound or skin therapy involved
Fistulas (abnormal tracts between two or more body areas) are common - Drug therapy: - Crohn’s disease
Might be needed: Not as successful because inflammation occurs along all areas/layers of the bowel involved so might need multiple/frequent surgeries
Surgery may be needed - Drug therapy: - Crohn’s disease
A client is admitted to the hospital with left lower quadrant pain, an elevated temperature. What problem might the nurse expect based on these clinical manifestations?
A. Gastroenteritis
B. Diverticulitis
C. Ulcerative Colitis
D. Crohn’s Disease
Answer: B
Abdominal pain (LLQ)
Temperature > 101 F - elevated temp
Lower GI bleeding
Nausea
Clinical manifestations of diverticulitis:
An abdominal computerized tomography (CT) is performed to confirm diagnosis of diverticulitis. A complete blood count is also completed. What results does the nurse anticipate?
A. Elevated hemoglobin
B. Decreased platelet count
C. Elevated white blood cell count
D. Decreased bilirubin
Answer: C
Gastroenteritis is an inflammation of the mucous membranes of the stomach and intestinal tract usually secondary to a virus or bacteria - ate something bad or stomach virus
Diverticulitis is an inflammation of diverticuli (outpouching of the intestinal wall) in the intestines
The client tells the nurse that they just think they ate “something bad”. How best does the nurse explain the difference between gastroenteritis and diverticulitis?
nausea/vomiting; diarrhea; abdominal cramping; can lead to dehydration - n/v/d
Clinical manifestations: - Gastroenteritis
Oral rehydration or IV fluids - can be treated as outpt but if dehydration bad need IVF
Monitor VS, I/O, weight
VS decreased because of diarrhea
Monitor electrolytes
Drugs that suppress intestinal motility (antidiarrheals) are usually not administered - ammodium carefully given
Antibiotics to treat bacterial gastroenteritis and anti-infective
Prevent transmission to others
Management: - Gastroenteritis
Potassium may be needed for patients with excessive diarrhea
Monitor electrolytes
These drugs can prevent the infecting organisms from being eliminated from the body
Drugs that suppress intestinal motility (antidiarrheals) are usually not administered - ammodium carefully given
Hand hygiene
Sanitize environmental items
Proper food preparation
Prevent transmission to others
Hypotension and tachycardia - VS
Decrease in H&H
GI bleeding - What complications would nurse be alert for when caring for a client with diverticulitis?
Severe abdominal pain and guarding
Rigid board like abdomen
Rebound tenderness - pain when lets go
Rupture of diverticuli and peritonitis - comp want to look out for: symp: - What complications would nurse be alert for when caring for a client with diverticulitis?
IV fluids
Drug therapy:
Assess fluid and electrolyte imbalance - check labs
Avoid increasing intra abdominal pressure
Diet modification
NGT
Surgery
What should be included in the management of care for a client diagnosed with diverticulitis?
Antimicrobial
Mild analgesic for pain or opioid analgesic - depending on how bad pain
Avoid laxatives or enemas as they increase intestinal motility
Drug therapy:
NPO, clear liquids, or low fiber diet - decrease peristalsis
Fiber containing diet is gradually introduced when inflammation has resolved and bowel function returns to normal
Diet modification
If N/V or abdominal distention is severe
NGT
Indicated if peritonitis, bowel obstruction or pelvic abscess is present - emergency
Colon resection, with or without colostomy
Surgery
