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med surg 2 > Iflammatory Bowel Disease > Flashcards

Iflammatory Bowel Disease Flashcards

1
Q

Definition

A
  • is a term encompassing a number of chronic inflammatory disorders leading to damage of the GI tract.
  • it is the most common digestive ailments affecting more than 1.4 million americans
  • IBD includes ulcerative colitis and crohn’s diseaese
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2
Q

INFLAMMATORY BOWEL DISEASE

A
  • autoimmune disease
  • chronic inflammation with remissions and exacerbations
  • inflammation and consequences are different for crohn’s and ulcerative colitis
  • serious digestive problems
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3
Q

EITIOLOGY IS UNKNOWN

A
  • genetic and environmental factors
  • infectious agents
  • altered immune responses
  • autoimmunity
  • lifestyle (smoking)
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4
Q

MANIFESTATIONS OF INFLAMMATORY BOWEL DISEASE

A

MUSCULOSKELETAL

  • peripheral arthritis
  • sacroiliitis
  • osteoporosis
  • ankylosing spondylitis

OCCULAR

  • uveitis
  • scleritis
  • episcleritis

VASCULAR
- thromboembolic events

RENAL
- nephrolithiasis(stones)

DERMATOLOGIC

  • erythema nodosum
  • pyodema gangrenosum
  • aphthous stomatitis

HEPATOBILIARY DISEASE
-primary sclerosing cholangitis

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5
Q

THERAPIES USED BY INTERDISCIPLINARY TEAM

A
  • diagnostic tests
  • pharmacologic therapy
  • teaching
  • surgery, including ostomies
  • complementary and alternative therapy
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6
Q

RISK FACTORS

A
  • peaks at 15-30 years of age
  • equally in men and women
  • second peak in the 50’s
  • use of NSAIDS and antibiotics increase risk of UC
  • smoking increase risk of CD
  • African americans and whites> Hispanics or Asians
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7
Q

CHRON’S DISEASE CLINICAL MANIFESTATIONS

A
  • usually starts in the TI but goes from mouth to anus.

- cobblestone appearance in bowel wall with patchy distribution

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8
Q

SYMPTOM’S OF CROHN’S DISEASE

A
  • fevers, night sweats, and weight loss(nutrition deficit)
  • abdominal pain
  • nausea and vomiting
  • diarrhea and /or constipation
  • rectal bleeding

depends on site and severity

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9
Q

CLINICAL MANIFESTATIONS INTESTINAL COMPLICATIONS

A 
intestinal obstruction
abscesses
fistulas
perforation
massive hemorrhage
colon cancer
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10
Q

PHYSICAL EXAMINATION IN CD

A
  • weight loss and pallor
  • clubbing of the fingers
  • abdominal distention
  • tenderness in the area of involvement
  • abnormal bowel sounds
  • presence of an inflammatory mass are common
  • perianal abscess, fistula skin tags or anal stricture
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11
Q

IMAGING STUDIES

A
  • plain abdominal x-ray (lower x-ray series)
  • barium studies(small bowel enema, large bowel enema)
  • Ultrasound of abdomen ,pelvis transrectal
  • CT abdomen and pelvis
  • MRI
  • sigmoidoscopy
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12
Q

_____ is an inflammatory bowel disease known for its cobblestone appearance.

A

Crohns

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13
Q

DEFINTION OF DISEASE SEVERITY GUIDELINES MILD - MODERATE CD

A
  • ambulatory patients
  • patients who are able to tolerate oral medications
  • patients without manifestaions of :
  • dehydration
  • toxicity(high fever, rigors, prostration)
  • painful mass
  • abdominal tenderness
  • obstruction
  • > 10% weight loss
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14
Q

DEFINTION OF DISEASE SEVERITY GUIDELINES MODERATE - SEVERE CD

A
  • patients who have failed to respond to treatment for mild- moderate disease
  • patients with more prominent symptoms of :
    *fever
    *significant weight loss
    *abdominal pain or tenderness
    *intermittent nausea or vomiting
    significant anemia
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15
Q

DEFINTION OF DISEASE SEVERITY GUIDELINES SEVERE CD

A

patient with persistent symptoms despite the introduction of steroids as out patient

  • individuals presenting with:
  • high fever
  • persistent vomiting
  • rebound tenderness
  • evidence of abscess
  • evidence of intestinal obstruction
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16
Q

CD IN REMISSION

A
  • patients who are asymptomatic or without inflammatory
  • patients who have responded to acute medical intervention or have undergone surgical resection without gross evidence or residual disease
  • patients requiring steroids to maintain well-being are considered to be “steroid- dependent” and are usually not considered to be in remission
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17
Q

CURRENT GOALS FOR CD THERAPY

A

Top Down

  • induce clinical remission
  • maintain clinical remission
  • improve quality of life
  • minimize progression of disease

PLUS

  • heal mucosa
  • decreases hospitalization/ surgey/ overall costs
  • minimize disease - related and therapy related complication
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18
Q

RECOMMENDED TREATMENT FOR MILD TO MODERATE CD

A

MILD:
- antibiotics and aminosalicylates

MODERATE :
- immunomodulators and cortecosteroids

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19
Q

AMINOSALICYLATES -FIRST LINE THERAPY

A
  • decrease GI inflammation
  • effective in achieving and maintaining remission
  • for mild to moderate episodes
  • causes fever adverse effects than sulfasalazine
  • inexspensive and effective for many patients that tolerate it
  • oral delayed release
examples:
pentasa , apriso, 
works best in colon 
horse pill 
pt must take 6
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20
Q

ANTIBIOTICS

A

frequently used with flare ups
are used when abscesses form

examples: metrodazole, ciprofloxacin, rifaximin

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21
Q

Immunodilators

A
  • suppress immune response
  • most useful in those who do not respond to aminosaliacylates , antibotics, or corticosteroids
  • require regular CBC monitoring
  • example:
  • tacrolimus

promezious test done to see if pt can tolerate

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22
Q

corticosteroids

A

-decrease inflammation
-used to achieve remission
-helpful for acute flare up-s
-
example:
prednisone
hydrocortisone

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23
Q

MODERATE-SEVERE CD

A
  • corticosteroids
  • biologic therapies
  • surgery
24
Q

BIOLOGIC THERAPIES

A

target proteins that play a role in inflammation intended for long term use can help maintain remission

25
Q

NURSING CONSIDERATIONS

A 
nonadherence
lack of knowledge
concerns about side effects
lack of trust in medication
diminished sense of priority for medication 
concern about side effects
burden of taking the prescribed med
treatment cost
26
Q

ALTERNATIVE AND COMPLEMENTARY TREATMENT

A
  • antidiarrheal
  • probiotics
  • vitamin B12
  • zinc
  • Iron
  • Folate acid
  • calcium
  • potassium
  • Iron
  • HERBALS, otc
27
Q

SEVERE CD TREATMENT

A

-hospitalization
-high recurrence
-surgery :
obstruction
peritonitis
excessive bleeding
exploratory laparotomy

28
Q

ULCERATIVE COLITIS

A

a chronic diseases characterized by diffuse mucosal inflammation limited to the colon

29
Q

UC CLINICAL MANIFESTATIONS

A
  • 5-30stools per day with blood and mucus
  • cramping in LLQ abdomen relieved by BM
  • common nutritional deficits
  • anemia, low albumin, weight loss
  • FEVER IS RARE
30
Q

SEVERE UC

A
  • blood stools >5 per day
  • tachycardia
  • temperature(>37.8)
  • anemia (hg 30)
31
Q

CLINICAL MANIFESTATIONS SEVERE COMPLICATIONS

A
  • arthritis 1 or more joints
  • skin and mucous membrane lessions
  • uveitis
  • thromboemboli
  • sclerosing cholangitis
  • hemmorage with anemia
  • perforation
  • carcinoma
  • rupture of bowel
  • toxic megacolon
32
Q

PHYSICAL EXAM OF UC

A
  • weight loss and 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
33
Q

UC MEDICAL THERAPY

A

-medication treatment is based on the severity of symptoms :

  1. Aminosalicylates
  2. Glucocorticoid
  3. Immunomodulators
  4. antibiotics
  5. Biologic
34
Q

UC DIAGNOSIS

A
  • rule out infectious causes through stool cultures
  • blood workup- check for anemia and infection
  • promethus panel
  • small bowel follow through
  • endoscopic examination
  • sigmoidectomy
  • total colonoscopy
  • chromoendoscopy
35
Q

COALS FOR MANAGEMENT OF ACUTE ULCERATIVE COLITITS

A
  • induction of remission
  • prevention of relapse
  • treatment of complications
36
Q

UC SURGERY

A

Indications
-fails to respond to treatment
-exacerbations are frequent and debilitating
- massive bleeding, perforation, strictures and or obstructions
- tissue changes suggest dysplasia is occurring
- Cancer
25-40% of pt will need surgery

37
Q

SURGERY

A
  • 2 steps 8-12 weeks apart
  • 1st step -colectomy, rectal mucosectomy, ileal reservoir, construction (temporary ileostomy)
  • 2nd step- closure of ileostomy to direct stool toward new reservoir
  • adaptation of reservoir 3-6 months

RESULTS:
decrease number of BM per day
control of defecation at anal sphincter

38
Q

OSTOMIES TYPES

A

ILEOSTOMY :
-opening into the 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

39
Q

PEROPERATIVE CARE

A
  • psychological support and explanations
  • enterstomal clinician will see optimal placement of stoma
  • Diet: high calorie, high protein, high carb, low residue a week before, NPO after midnight
  • general preop teaching
  • NG or intestinal tube post op
  • Antibiotics day before surgery
  • laxatives, enemas, evening before and morning of surgery
40
Q

ILEOSTOMY

A
  • 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
  • stoma is smaller
41
Q

ILEOSTOMY DIETARY CONCERNS

A

Goal- return to normal pre-surgical diet and avoid foods that cause diarrhea, gas or obstruction

  • Low fiber diet 4-6weeks
  • prone to food blockage with non digestible fiber intake (know signs)
  • use care when eating high fiber foods
  • one food at a time
  • 10-12 glasses of water per day
42
Q

BLOCKAGE

A

KEEP NPO

  • remove pouch if stoma swollen
  • warm bath 15 minutes
  • peri- stomal massage (knee to chest position)
  • may use warm saline irrigation if other measures do not work
  • do not irrigate routinely to regulate frequency of BM
  • call doctor, ostomy nurse or go to ER if blockage lasts for 2 hours or if starts to vomit
43
Q

COLOSTOMIES

A
  • ascending colon
  • transverse double barrel colostomy
  • sigmoid colostomy
44
Q

ASCENDING COLOSTOMY

A
  • RUQ abdomen
  • all portions distal are removed
  • permanent colostomy
  • feces is semiliquid
  • skin breakdown common
45
Q

TRANSVERSE DOUBLE BARREL COLOSTOMY

A
  • 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
46
Q

SIGMOID COLOSTOMY

A
  • single barrel
  • usually permanent (cancer of rectum)
  • formed feces
  • drainage may be regulated by irrigation
  • ostomy appliance may eventually not be needed
47
Q

GENERAL POSTOP CARE

A
  • NPO, NG or intestinal decompression until bowel sounds return, progress from clear liquid to solid , low fiber diet for 6-8 wks
  • monitor I&O, keep electrolytes balanced
  • observations of stoma and drainage
  • first few days….beefy red and swollen
  • gradually swelling recedes and color is pink or red
  • notify MD immediately with dark blue , blackish or purple stoma
  • drainage mucus or serosanguinous for first 1-2 days
  • begins to function 3-6 days after surgery
48
Q

POSTOP CARE

A

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 ( may include skin prep, paste, powder).
  • 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
49
Q

EFFECTS OF FOOD

A

THICKEN STOOL:
- applesauce, creamy peanut butter, bananas, boiled milk, buttermilk, cheese, pasta, rice, pretzels, tapioca pudding, toast yogurt

LOOSEN STOOL:
- alcohol, broccoli, green beans, fresh fruit except bananas, grape juice, prunes, spicy food, spinach

CAUSES GAS:
-beans, beer, broccoli, brussel sprouts, cabbage, carbonated beverages, corn, cauliflower, cucumbers, mushrooms, spinach, peas

50
Q

EFFECTS OF FOOD

A

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 vegetables, dried fruits, grapes, meats with casings (hot dogs), nuts,mushrooms, pineapple, popcorn, large seeds

DISCOLOR STOOL
-beets, red gelatin

51
Q

IRRIGATING COLOSTOMY

A

ONLY A COLOSTOMY CAN BE IRRIGATED

  • never use an enema set to irrigate a colostomy
  • 500-1000ml lukewarm water through lubricated cone slowly over 5-10 min
  • remove cone and allow 30-45min for solution and feces to return
  • close off irrigation sleeve after 10-15min
  • clean , rinse and dry the peristomal skin well , apply stoma cap or pouch
  • wash and rinse all equipment and hang dry
52
Q

PERFECT STOMA

A
  • preoperatively sited
  • budded
  • visible too patient
  • no complications
53
Q

IMPERFECT STOMA

A

-flushed
-retracted or recessed
CALL DOCTOR

54
Q

COMMON POST-OP COMPLICATIONS

A
  • necrosis
    -bleeding
  • prolapse
    -parastomal hernia
    -mucocutaneous separation
    CALL DOCTOR
55
Q

ASSESSMENT/ CARE

A
  • healthy color (increased vascularity)
  • rose,redish pink or brick red
  • edema
  • mild to moderate is normal initinally
  • bleeding
  • small amount 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
  • change wafer every 3-7days
56
Q

DRAINAGE ASSESSMENT/CARE

A

minimal 24 to 48 hrs after serosanguinous until peristalsis returns

liquid to semi liquid-1000-1800ml/day

decreases to 500 with proximal bowel adaptation

sodium and potassium -significant lost with drainage

med surg 2 (17 decks)

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