Lower GI Problems Flashcards
Appendicitis is commonly caused by?
Obstruction of the lumen by feces, foreign bodies, tumor of the cecum or appendix, thickening of lymphoid tissue
Appendicitis can lead to?
Abscess
Gangrene
Perforation
Peritonitis
Appendicitis S/S
- Difficult to diagnose
- Pre-umbilical pain
- anorexia
- N/V
- Pain is continuous and shifts to right lower quad and localizes at McBurney’s point
- Localized tenderness
- rebound tenderness
- muscle guarding
- pain worsens with coughing, sneezing, and deep breathing
- Wants to lay still-right leg flexed
- May have fever
Older Adults S/S of Appendicitis?
- Discomfort –R iliac fossa
- Pain is less severe
- Slight fever
- Diagnosis often delayed
- Higher incidence of ruptured appendix and peritonitis
- Higher fatality due to co-morbidities
Appendicitis Diagnostics
- WBC-mildly to moderately elevated
- Urinalysis-r/o GU problems
- US
- CT preferred
Treatment of Appendicitis?
- Immediate-Urgent Appendectomy
- NPO
- Treat pain
- ice pack & medications
- Antibiotics & IVF before surgery and after
- 6-8 hours before OR if possible – prevent sepsis and dehydration
Preferred diagnostic procedure for appendicitis?
CT
Patient Teaching for Appendicitis?
- Patients with suspected appendicitis should NOT use laxatives or enemas
, or apply heat to the painful area - Can result in perforation or rupture of appendix
Post Op Nursing Interventions
- Watch for peritonitis (can occur with or without perforation)
- Ambulate day of surgery
- Assess incision
- Advance diet as tolerated
Localized or generalized inflammatory process of the peritoneum
Peritonitis
Causes for Primary Peritonitis?
- blood-borne organisms
- genital tract organisms
- cirrhosis with ascites
Causes for Secondary Peritonitis?
- Peritoneal dialysis-HIGH risk;
- ruptured appendix
- diverticulitis rupture
- ischemic bowel
- pancreatitis
- perforated peptic ulcer
- gun shot or knife wounds
Pathophysiology – organ ruptures, spills contents; chemical peritonitis initially followed by bacterial peritonitis in?
6 -8 hours
S/S of Peritonitis
- Abdominal pain
- rebound tenderness
- Pt lies still with shallow respirations
- spasm
- Abdominal distension or ascites
- fever
- tachycardia
- tachypnea
- N/V
- altered bowels habits
Complications of Peritonitis?
- Hypovolemic shock
- sepsis
- intra-abdominal abscess
- paralytic ileus
- respiratory distress
- Can be fatal if not treated
Peritonitis Diagnostics
- CBC-elevated WBC count
- Abdominal Xray
- Ultrasound
- CT scan
- Paracentesis (peritoneal aspiration)
- Peritoneoscopy
- Cell count of peritoneal dialysis drainage
What does it indicate if a patient with suspected Peritonitis has an ABD x-ray showing free air?
perforation
What does it indicate if a patient with suspected Peritonitis has an ABD x-ray showing dilated loops?
parylytic ileus
What does it indicate if a patient with suspected Peritonitis has an ABD x-ray showing air and fluid?
obstruction
Treatment of Peritonitis?
- Treat the cause
- Surgery to correct inflammation and drain purulent fluid
- Medical
- if mild or pt poor candidate for OR, start an NG & antibiotics – hope tear repairs self
- Antibiotics-almost all patients
- NPO/NG suction
- Analgesics, antiemetics, sedatives
- Position - knees flexed
- IV fluids
- Monitor I&O
- Drain care-if present after OR
Nursing Assessments for Peritonitis?
focused on Pain, abdominal, VS, urine output, hypovolemic shock
Nursing Interventions for a patient with Peritonitis?
- IV (fluid replacement and antibiotics)
- NG monitoring and care
- I&O
- N/V
- drain monitoring
- incision and drain site care
Types of Inflammatory Bowel Disease (IBD)
Crohn’s disease and ulcerative colitis
What part of the GI is affected in a patient with Crohn’s disease?
can occur anywhere in the GI tract (mouth to anus)
Crohn’s disease most often affects the?
terminal ileum and colon
Crohn’s affects which layers of the bowel wall?
all of them
Inflammation and ulceration of the colon and rectum
Ulcerative colitis
Pathology of Ulcerative colitis?
starts in the rectum and moves towards the cecum
Ulcerative colitis affects which layers of the bowel wall?
- the mucosal layer or inner most layer, which is why uclers are rare
Signs and Symptoms IBD (Crohn’s and UC)
Diarrhea Bloody stool Fatigue Abdominal pain Weight loss Fever
Main symptoms of Crohn’s?
- Diarrhea
- Colicky abdominal pain (comes and goes)
- Fever
symptoms of crohns if the small intestine is affected?
- weight loss due to malnutrition
- nutritional problems
Main symptoms of UC?
- Bloody diarrhea if severe
- Abdominal pain
- Rectal bleeding
- Severity can range from 1-20 stools per day
IBD: Diagnostic Studies
- Rule out other diseases
- H & P
- Blood studies
- CBC-iron deficiency or blood loss
- WBC-toxic megacolon or perforation
- Serum electrolyte levels
- Serum protein levels
- Serum albumin levels
- Stool cultures
- Blood
- Pus
- Mucus
IBD: Diagnostic Procedures
- Sigmoidoscopy w/ biopsy
- colonoscopy w/ biopsy (preferred)
- Double-contrast barium enema
- Identifies areas of ulceration
- Capsule endoscopy
- CT, MRI, transabdominal US, small bowl series
Which diagnostic procedure has the greatest sensitivity for diagnosing Crohn’s Disease?
Capsule Endoscopy
IBD: Complications
- Nutritional deficits
- Hemorrhage
- Strictures
- Perforation (with possible peritonitis)
- Fistula with Crohn’s
- Perineal abscess with Crohn’s
- Toxic megacolon with Ulcerative Colitis
What are S/S of Toxic Megacolon?
- Dilation and paralysis of the colon, associated with perforation.
- Abdominal pain, distension and tenderness
- Tachycardia
- Loss of bowel sounds
In Crohn’s fistulas can develop where?
between the bowel and bladder, and the bowel and vagina
IBD Systemic Complications
- Inflammation of joints, eye, mouth, kidneys, bone, vascular, and skin due to an increase in circulation of cytokines
- Increase risk of liver failure – sclerosing cholangitis develops
IBD Treatment
- Hemodynamically stable
- Monitor H/H, Vital signs
- res to the bowels
- Hydrate-IVF
- Monitor electrolytes
- Pain control
- Nutritional support (TPN in severe cases)
- May need surgery
Diet for IBD when they can tolerate it?
high calorie, high vitamin, high protein, low residue, lactose free diet when eating
Drug Therapy for IBD?
- Aminosalicylates
- Antimicrobials
- Corticosteroids
- Immunosuppressants
- Biologic and targeted therapy
Complications related to an exacerbation of IBD?
- Massive bleeding
- Perforation
- Strictures and/or obstruction
- Toxic megacolon
- Tissues changes indicating dysplasia or carcinoma
Post Op Care for IBD?
- I&O
- Initial ileostomy output 1500-1800/2000mL per 24hr
- Normal 500mL/day
- Assess Stoma –shrinkage, output
- Assess for:
- Fluid & electrolyte imbalance
- Hemorrhage
- Abdominal abscess
- SBO (no bowel sounds, vomiting, no BM’s)
- Dehydration
Teaching for IBD?
- Rest
- Dietary modification`
- Smoking cessation
- Stress reduction
- Medication adherence
- Supplements as needed
- Ca, Iron, Zinc
- Stoma care-if stoma present
- Perianal skin care
2nd peak of IBD after what age?
60 y/o
Causes of Intestinal Obstruction?
- Mechanical- detectable occlusion commonly in the small intestine
- Non-mechanical
Causes of Mechanical Intestinal Obstruction?
- Surgical adhesions
- hernia
- strictures from Crohn’s
- diverticulitis
- tumor
Causes of Non-Mechanical Intestinal Obstruction?
- Paralytic ileus
- lack of peristalsis
- absence of bowel sounds
Clinical Manifestations of poximal SBO? A) Onset B) Vomitting C) Pain D) Bowel movement E) Abd distention
A) rapid B) frequent & copious C) colicky, cramping occurs at frequent intervals D) feces for a short time E) minimal
Clinical Manifestations of LBO? A) Onset B) Vomitting C) Pain D) Bowel movement E) Abd distention
A) gradual B) late or absent C) low-grade, persistent cramping abd pain D) absolute constipation E) Increased
Early common S/S of Intestinal Obstruction?
- N/V, abdominal pain & distension
Late common S/S of Intestinal Obstruction?
inability to pass flatus, constipation, may show s/s of hypovolemia
Diagnostics for Intestinal Obstruction?
- Absent or high pitched BS above obstruction
- CT Scan and abd Xray
- Sigmoidoscopy or colonoscopy to visualize obstruction
What does it indicate if a patient with suspected Intestinal Obstruction has an ABD x-ray showing the following:
A) Presence of air on scan
B) Dilated loops
C) Air and fluid
A) perforation
B) paralytic ileus
C) obstruction
Clinical Manifestations of Distal SBO? A) Onset B) Vomitting C) Pain D) Bowel movement E) Abd distention
A) rapid B) less frequent C) colicky, cramping occurs intermittently D) gradual constipation E) increased
diagnostic labs for an Intestinal Obstruction?
- CBC
- Electrolytes
- BUN
- Creatinine
- ABG
- Stool-occult blood
An elevated WBC in a patient suspected of having an Intestinal Obstructions indicates?
strangulation or perforation
A decrease H/H in a patient suspected of having an Intestinal Obstructions indicates?
hemorrhage or strangulation
Intestinal Obstruction Treatment?
- NPO
- Hydrate IVF- watch for fluid over load
- NG tube
- Oral care
- Patency
- Skin breakdown
- Total Parenteral Nutrition
- May need to prep pt for surgery
- Resection
- Resection with ostomy if obstruction is extensive or necrosis is present
Nursing Assessments for Intestinal Obstruction?
- Monitor for dehydration and electrolyte imbalances
- Assess pain
- Assess emesis (if present) - Bowel sounds
- is pt passing gas
- when was last BM
- Abd distension-look for abdominal scars & masses
- Measure abdominal girth
- Strict I&O
If waiting for intestinal obstruction to resolve on own assess for _______ and report an urine output of _______?
- changes in urine output, VS, BS, rising BUN/Cr, increase in pain or distention
- urine output < 0.5mL/kg/hr
Intestinal Obstruction Complications?
- Severe reduction in circulating blood volume and electrolyte deficiencies
- Hypotension
- Hypovolemic Shock
- Cardiac dysrhythmias
- Intestinal strangulation or intestinal infarction
Intestinal strangulation or intestinal infarction can cause?
- Inadequate blood flow
- Edema
- Cyanosis
- Gangrene
- Can lead to peritonitis
created when the intestine is brought through the abdominal wall and sutured to the skin
stoma
Major types of Ostomies?
- End stoma
- Loop stoma
- Double barreled stoma
- Assess stoma q______ and color should be?
-
- q4 hrs & PRN
- pink
Stoma colors:
A) Dusky blue = ___?
B) Brown-black = ___?
A) ischemia
B) necrosis
How often should a stoma pouch be change and should be empty when it is _______?
- q 4-7 days
- 1/3 full
Output amount from a:
A) colostomy
B) Ileostomy
A) mimic normal output
B) 1000-1800mL initially, then an average daily amount 500mL
How long surgery can a patient with an ostomy resume ADL?
6-8 weeks but should avoid heavy lifting
When should colostomy irrigation be used and why?
- only when the stoma is from the distal colon or rectum
- to promote regular evacuation of stool
how to perform a colostomy irrigation?
- hold Irrigation bag 18 – 24 inches above stoma
- use 500 – 1000mL warm water flow in over 5-10 minutes – 750mL is norm
- If cramping occurs, slow down rate, may stop water but do not stop the process
- Wait ½ to 1 hour and empty reservoir bag
- Initial evacuation occurs after 15 minutes
Ostomy Complications?
- Skin breakdown
- Infection
- Electrolyte imbalances
Electrolyte imbalances are seen more often in which type of ostomy?
- ileostomy
- K
- NA
- Fluid volume deficits
divides the bowel. Proximal end to skin. Distal end removed or left in place (Hartman’s pouch)
end stoma
loop of bowel up to surface – anterior portion = feces, distal portion = mucus drainage
loop stoma
2 separate stomas – works like loop stoma-usually temporary
double barreled stoma
In a loop stoma, the anterior portion = _____, distal portion = _________
1) feces
2) mucus drainage
