IBD: UC Flashcards
UC Definition
-chronic disease characterized by diffuse mucosal inflammation limited to the colon
UC Clinical Manifestations
- 5 to 30 stools per day with blood and mucus (severe)
- Cramping in LLQ abdomen relieved by BM
- Common nutritional deficits
- anemia, decreased albumin, weight loss
- fever (rare)
Severe UC
-bloody stool frequency of more than 5 per day with any one of the following:
- tachycardia (over 90 bpm)
- temp (over 37.8 C)
- anemia (less than 10.5 Hg)
- raised ESR (over 30)
Clinical Manifestations of Severe Complications
- arthritis 1 or more joints
- skin and mucous membrane lesions
- uveitis
- thromboemboli
- sclerosing cholangitis
- hemorrhage with anemia
- perforation
- rupture of bowel
- toxic megacolon
- carcinoma
Assessment for UC
- weight loss/pallor
- abdominal distension
- tenderness in the area of involvement
- abnormal bowel sounds
- presence of an inflammatory mass are common
- perianal abscess, fistula, skin tags, or anal stricture
UC Medical Therapy
-medication tx is based on the severity of symptoms
Five major classes used:
- aminosalicylates (5 ASA)
- glucocorticoid
- immunomodulators
- antibiotics
- biologic
UC Diagnosis
- rule out other infectious causes through stool cultures
- blood workup, check for anemia and infection
- prometheus panel
- small bowel follow through
- endoscopic exam: sigmoidoscopy, total colonoscopy
- chromoendoscopy
Goals for the Management of Acute Ulcerative Colitis
- induction of remission
- prevention of relapse
- tx of complications
UC Surgery
indications:
- fails to respond to tx
- exacerbations are frequent and debilitating
- massive bleeding, perforation, strictures and/or obstructions
- tissue changes suggest dysplasia is occurring
- cancer
25-40% of patients will need surgery
Steps to Surgery for UC
2 steps, 8 to 12 weeks apart
- Colectomy, rectal mucosectomy, ileal reservoir construction (temp. ileostomy)
- Closure of ileostomy to direct stool toward new reservoir 3-6 months
UC Surgery results
- decreased # BMs/day
- control of defecation at anal sphincter
Types of Ostomies
- Ileostomy
- Colostomy
Ileostomy description
opening into ileum to allow passage of intestinal content.
Intestine is sutured onto the skin surface creating a stoma
All portions of the large intestine are removed.
Can be permanent or temporary
Colostomy
opening into colon to allow passage of intestinal content
intestine is sutured onto the skin surface creating a stoma
Preoperative Care
- psych support and explanation
- enterostomal clinician for optimal placement of stoma
- diet modifications
- general preop teaching
- NG or intestinal tube post op
- antibiotics day before surgery
- laxatives, enemas evening before and morning of surgery
Preop diet modifications
- ↑ calorie
- ↑ protein
- ↑ carbs
- ↓ residue week before
- NPO after midnight
Ileostomy
- usually done for Crohn’s disease and ulcerative colitis
- permanent ostomy in RLQ abdomen
- Pouch must be worn at all times for liquid to semi-liquid drainage
- skin breakdown and fluid/electrolyte imbalance occur easily
Ileostomy Dietary Concerns
Goal: return to normal pre-surgical diet and avoid foods that cause diarrhea, gas, or obstruction
4-6 wks: low fiber diet
- prone to food blockage with non-digestible fiber intake (knows signs)
- use care when eating high fiber foods
Blockages
- Keep NPO
- Remove pouch if stoma swollen
- warm bath 15 minutes
- peri-stomal massage (knee chest position if possible)
- may use warm saline irrigation if other measures do not work
- do not irrigate routinely to regulate frequency of BM
- if blockage lasts for 2 hours or starts to vomit, call doctor, ostomy nurse or go to the ER
Colostomy Types
- Ascending colostomy
- transverse double barrel colostomy
- sigmoid colostomy
Ascending colostomy
- RUQ abdomen
- all portions distal are removed
- permanent colostomy
- feces is semiliquid
- skin breakdown common
Transverse Double Barrel Colostomy
- usually temporary
- may be permanent if distal portion is removed later
- semi-liquid to semi-formed feces
- distal end left to mature; has mucus in it
Sigmoid Colostomy
- single barrel
- usually permanent
- formed feces
- drainage may be regulated by irrigation
- ostomy appliance may eventually not be needed
General Post-op Care
- NPO: NG or intestinal decompression until bowel sounds return, progress from clear liquid to solid, low fiber diet for 6-8 weeks
- Monitor I&O, keep electrolytes balance
- observations of stoma and drainage
- first few days, beefy red and swollen
- gradually swelling recedes and color is pink or red
- notify MD immediately if stoma is dark blue, blackish, or purple
- drainage mucus or serosanguinous for first 1-2 days
- begins to function 3-6 days after surgery
Promote positive adjustment to ostomy
- encourage to look at stoma
- encourage early participation in care
- reinforce positive aspects of colostomy
- principles of skin care
- clean skin gently and pat dry, do not rub
- pouch opening 1/16th inch to 1/8th inch larger than stoma
- skin barrier to protect skin immediately surrounding stoma
- pouch is applied by pressing adhesive area to skin for 30 seconds
- empty appliance immediately when seal breaks or when 1/4 to 1/3 full
Thicken stool
- applesauce
- creamy PB
- bananas
- boiled milk
- buttermilk
- cheese
- pasta
- rice
- pretzels
- tapioca
- toast
- yogurt
Loosen stool
- alcohol
- broccoli
- grean beans
- fresh fruit except bananas
- grape juice
- prunes or prune juice
- spicy foods
- spinach
Causes gas
- beans
- beer
- broccoli
- brussel sprouts
- cabbage
- carbonated beverages
- corn
- cauliflower
- cucumbers
- mushrooms
- spinach
- peas
Causes stool odor
- asparagus
- brussel sprouts
- cabbage
- cauliflower
- eggs
- fish
- garlic
- onions
- some spices
May contribute to food blockage
- apple peels
- raw cabbage
- corn
- raw celery
- coconut
- chinese veges
- dried fruits
- grapes
- meats with casings (hotdogs or sausage)
- mushrooms
- nuts
- pineapple
- potato peels
- large seeds
Discolor stool
- beets
- red gelatin
Irrigating colostomy
- only a colostomy can be irrigated, distal colon or rectum
- never use an enema set to irrigate a colostomy
- 500-1000mL lukewarm water through lubricated cone slowly over 5-10 minutes
- remove cone and allow 30-45 minutes for the solution and feces to return
- close off irrigating sleeve after 10-15 minutes; most has returned to ambulate
- clean, rinse, dry and peristomal skin well. apply stoma cap or pouch
- wash and rinse all equipment and hang to dry
The Perfect Stoma
- pre-op sited
- budded
- visible to patient
- no complications
Imperfect Stoma
- flush
- retracted or recessed
Common post-op complications
- necrosis
- bleeding
- prolapse
- mucocutaneous separation
- parastomal hernia
Healthy color
- increased vascularity
- rose, reddish pink or brick red
- edema
- mild to moderate is normal intially
- bleeding
- small amount normal when touched
- skin around stoma
- most sensitive to pain and irritation
Skin irritation is…
avoidable
- keep clean and dry
- skin breakdown is a problem
-use warm tap water or other recommended products
Drainage
- minimal 24-48 hours after: serosanguinous until peristalsis returns
- liquid to semi-liquid: 1000 to 1800 mL/day
- decreases to 500mL with proximal bowel adaptation
- Na++ and K+ significant lost with drainage
Assessment/Care of Stoma
- change wafer q3-7 days and prn
- stoma changes or wafer sizing 1/16th inch to 1/8th inch larger than stoma
- drainage pouch
- empty when 1/4 to 1/3 full
- can use tissue to clean stoma
- can clean pouch with cool to lukewarm water
Pouch application
“less is more”
- begin with minimum of accessories and add as needed
- peristomal skin must be clean and dry
- can shave hair with electric razor if necessary to avoid folliculitis
- avoid oils, lotions, creams, soaps
- select optimal time for pouch change
Paste
caulk to fill skin defects
powder
moisture absorption for weeping skin
adhesive removal wipes
breaks adhesive bond
skin sealant
defats skin; avoid with extended wear wafer unless recommended by ostomy nurse
belt
secures appliance more closely to abdomen
Leakage prevention
- stoma opening sized correctly
- correct appliance
- pouch been emptied regularly
- empty when 1/4 to 1/3 full
- what is patient doing when pouch fails?
Followup teaching
- make followup appt
- call doctor right away if you have any of the following:
- changes in stoma
- drainage
- fever
- N/V
- pain
- no gas or stool after 24 hrs
Pre-op Education
- consistent education
- non-judgemental
- support groups/individuals (ostomy visitors)
Diet with flare up
- low residue diet=low fiber diet
- small frequent meals
- avoid “trigger foods”…no universal ones for IBD
- limit sugar, artificial sweeteners, spicy foods, caffeine, lactose
- replace fluid and electrolyte loss
- parenteral IVF or enteral feedings
- TPN for bowel rest
- prevent weight loss
Diet in Remission
Goal: adequate nutrition without exacerbating symptoms
-Best…balanced diet…increase protein, increase calorie, decrease fat, decrease fiber
Nursing intervention to promote rest during flare-ups
- freq. breaks and rest
- good quality sleep
- alternative therapies such as acupuncture, yoga, or homeopathy
- planning ahead and reducing stress
- physiotherapy and exercise
- flexible work hours
Intervention body image
- listen to patient’s feelings and self perception
- encourage patient to discuss physical changes
- encourage patient to discuss their concerns about the disease and tx on close personal relationships
- encourage the patient to make choice and decisions about own care, increases sense of control
Discharge teaching
- importance of rest
- perianal care
- action and SE of meds
- symptoms of recurrence of disease
- when to seek medical care
- use of diversional activities to reduce stress
- teaching resources from Chrohn’s and Colitis Foundation of America
