Med-Surg 2: GI/Hepatic/Pancreas Disorders Flashcards
Some risk factors for IBS?
- High fat diet
- Alcohol
- Smoking
- Carbonated beverages
- Caffeine
- Stress
- Women more than men
Functional disorder of motility of the intestines =
Irritable Bowel Syndrome.
Clinical Manifestations of IBS:
- Abdominal pain/cramping
- Often after meals
- Bloated feeling
- Flatulence
- Diarrhea and/or constipation
- Relief after defecation: hallmark usually
- Mucus in the stool
What is the Rome II symptom-based criteria for IBS?
- Abdominal pain/discomfort for at least 3 consecutive months within 12 months
- Symptom relief with defecation
- Change in frequency/appearance of stool
- mucous or ribbon-like
How do you diagnose IBS?
- No specific test
- Diagnosis of exclusion
- Rule out lactose intolerance
- Colonoscopy: more of a rule-out thing
- Rome III symptom-based criteria
- Abdominal pain x 3 months
- Symptom relief with defecation
- Change in frequency/appearance of stool
- mucous or ribbon-like
How do you manage IBS?
- Stress reduction: walking dog, warm bath, whatever reduces stress; even a glass of wine
- Avoid food triggers
- Fiber- 20 gms/day (plus hydration!)
- proceed with caution!! Do gradually.
- avoid gas producing foods: cabbage
- Bulking agents- Metamucil
- Probiotics: healthy bacteria; in certain yogurts, etc.
- Meds- Loperamide (Imodium)–for diarrhea; slows GI motility, Lotronex (severe IBS) Anticholinergics (Bentyl, Levsin)–may make sleepy, dizzy so may need to lie down when first taking.
What are some meds to take for IBS?
- Bulking agents- Metamucil
- Probiotics: healthy bacteria; in certain yogurts, etc.
- Meds- Loperamide (Imodium)–for diarrhea; slows GI motility, Lotronex (severe IBS) Anticholinergics (Bentyl, Levsin)–may make sleepy, dizzy so may need to lie down when first taking.
What do you need to tell the patient about Levsin and Bentyl?
It may cause dizziness and somnolence so they may need to lie down after they take it.
What quadrant would appendicitis be in?
RLQ
What are some things that can cause appendicitis?
Fecalith (a fecal calculus or stone) that occludes the lumen of the appendix; kinking/twisting of appendix; occlussions; infection; fibrous conditions; etc.
What are three complications of Appendicitis?
Rupture/perforation; Peritonitis; gangrene.
Clinical Manifestations of Appendicitis?
- Nausea/vomiting
- Acute abdominal pain
- Positive McBurney’s test: Push down on RLQ and lift up; pain when lifting up–rebound tenderness
- Pain can start in epigastric/periumbilical
- Progression to RLQ pain
- Guarding
- Sometimes only slight leukocytosis: unless ruptured appendix
- May have a low grade fever
Would you put ice or heat on the painful spot caused by appendicitis?
ICE. Heat could cause rupture.
Do you do a bowel prep pre-op for appendicitis?
NO bc it could cause rupture.
What kind of diet should a person with IBS have?
High-fiber, low-fat, well-balanced; avoid problematic foods, carbonated beverages, limit smoking/alcohol
Which test can you perform to test for appendicitis?
McBurney’s: press down on the RLQ and will have pain when lifting up (rebound tenderness)
Post-op care for Appendicitis:
- Risk for infection- Perforation
- Risk for decreased fluid volume related to vomiting
- NGT (to decompress stomach bc of n/v), monitor I/O, Diet?–still gonna be NPO for a couple days because of no peristalsis; will do TPN after a while–try to hold off until they really have to (have to have central line, it’s expensive); may do J-tube–enteral feeding preserves gut integrity (“don’t use it, you lose it”).
- Pain management: PCA pump or IV meds usually
- Up first post day
- Restrict lifting for 3-4 weeks post-op
- Other usual post-op care for abdominal surgery patient
- Common complaint after Lap surgery is the pain in the shoulder from the CO2 traveling upwards; can apply warm blanket to shoulder.
- All other rules for post-op abdominal surgeries applies.
After an appendectomy, restrict lifting for ____
3-4 weeks
S/S of Peritonitis:
- Sudden onset
- Fever
- Increased pain
- Guarding, spasms
- Vital signs? Increase in BP/Tachy/RR in beginning because of pain; increased RR, but depth of respirations will be shallow because it hurts to breathe in–risk for atelectasis/pneumonia later on; if they go into sepsis, BP may drop because of fluid shifts
- Bowel sounds? decreased.
- N/V
- Rigid board-like abdomen*
- Elevated WBC: because of infection.
Management of Peritonitis:
- Prevent with early dx of abdominal infection, meticulous abd. assessment!
- Bowel rest (NPO)/ NGT to LWS (low wall suction)
- Dressing changes/drains: often large dressing changes; wet-to-dry; wound vac maybe; may need Penrose or JP drain–make sure to label drains (right side/t-tube/whatever it is); make sure to record drainage
- IV antibiotics
- F&E balance
- Analgesics
- Prevent complications of immobility
Crohn’s is more common in the ___ intestines (terminal ileum); thus, the ___ &__ quadrants would be involved. However, the ___ can also be involved.
small; RUQ & RLQ; ascending colon.
Crohn’s appearance?
Cobblestone, skipped lesions.
Ulcerative Colitis affects ____; it starts in the ___ and spreads ____; Therefore, it starts on the ___ side. There are distinct ___ between healthy and diseased colon.
entire length of colon; rectum; upward; left; demarcations;
Diarrhea can be in both Crohn’s and Ulcerative Colitis, but it is more frequent in ____.
UC
With Crohn’s, the ___ is involved which results in altered ___ metabolism which results in _____.
ileum; fat metabolism; steatorrhea (fat in stool).
Clinical Manifestations of IBD (Crohn’s and Ulcerative Colitis):
- Diarrhea in both– but, more frequent with ulcerative colitis
- Stool characteristics? Can be up to 20/day (especially in ulcerative colitis)
- Crohn’s-ileum is involved, altered fat metabolism: ileum normally absorbs fat; steatorrhea (fat in stool).
- Cramping: in both
- Weight loss
- Nutritional deficits
- Decreased iron binding capacity, malabsorption (A,D,E,K–fat soluble vitamins)
- Abdominal assessment/ and pain
- Dehydration: high risk
- Rectal bleeding: especially with UC
How long can TPN hang?
24 hours
What do you need to do/think about when using TPN?
We don’t have to spike tubing; pharmacy does it; Can only hang for 24 hours and then you change it; lipids may be hung separately; Do accuchecks with pt because there’s high concentrations of glucose (insulin may be put into it); has lots of stuff in it; Will need to monitor electrolyte levels (because TPN has a lot of stuff in it); Physician has to order it; Daily weights will need to be done
-Do you check residuals and/or placement with J-tube? NOPE. You do with G-tube/PEG.
Management of Ulcerative Colitis and Crohn’s?
- Fluid & electrolyte balance
- Manage diarrhea
- Anti-diarrhea meds- immodium
- Labs, monitor weight, I&O
- Bowel rest: NPO
- What about nutrition? Enteral or TPN
- Preferred route of nutrition if possible? Enteral preferred; surgeon has to insert J-tube, though.
- Elemental diets
- TPN may be necessary (total parenteral nutrition): increases risk for sepsis from breaking down of gut integrity
Nutrition for IBD?
- Follow My Pyramid guidelines if they are able.
- No smoking- increases GI motility
- Small frequent meals
- Individualize diet plan
- Food diary to ID “problem” foods
- Reduce high fat foods esp. if large portion of ileum removed/diseased
- Evaluate for lactose intolerance
- Low-fiber, low-residue often recommended
- Easily digested foods-what are they? Clear liquids, broth, mashed potatoes, refined flours, baked meats (no fried shit); NO cabbage/broccoli
Supplementation
- B12 if ileum inflamed or removed
- Lack of B12 prevents RBC maturation=anemic; may need injections of B12
- Folic acid (folate)- especially if on Azulfidine–causes folate deficiency even more.
- Multivitamin
- Malabsorption of fat soluable vitamins
- (A,D,E,,& K) **decreased Vit K= Bleeding potential
- Supplement iron if anemia present
- Monitor for electrolyte deficiencies
- Calcium
Azulfidine causes ___ deficiency.
folate.
Decreased Vitamin K = potential for _____
bleeding.
People with a lack of B12 may be _____
anemic.
With Azulfadine, monitor for allergy to _____
sulfa; it’s a combo of ASA & sulfa.
Remicade is an IV drug used for _____
Crohn’s.
What adverse reactions do you have to worry about with Remicade (infliximab) and Humira (adalimumab)–(Tumor Necrosis Factor Inhibitors)?
Risk of allergic Rx/transfusion reaction (chills, aching, diaphoresis, trouble breathing, possibly back pain), infections, reactivating TB, hepatitis/liver damage, lymphoma, & Bone marrow suppression.
First-line meds for IBD =
Anti-tumor necrosis factor
Azulfidine is used for ______
Ulcerative Colitis
Asacol and Colazol are used for ____ and have less side effects than Azulfidine.
Ulcerative Colitis.
Comes in a suppository form, used for distal IBD disease.
Rowasa.
Imuran may take ____ months to work.
6
What is a risk for Imuran?
allergic IV reaction.
What is an immunosuppressive med given for IBD?
Imuran.
Removing the diseased portion of the intestines for a patient with _____ may provide a cure.
Ulcerative Colitis.
Clinical Manifestations of Diverticulosis:
- Diverticulitis: inflammation of diverticuli
- Crampy abdominal pain
- Nausea
- Alternate between diarrhea and constipation
- Flatus
- Low grade fever
Risk factors for diverticulosis:
Low fiber diet; congenital predisposition.
Prevention of Diverticulitis:
- Prevent constipation
- High fiber diet – foods? 20 grams a day
- Hydration: drink lots of water with fiber! Constipation will be worse if they don’t; Whole grains, whole wheats, veggies; they ARE able to eat nuts/tomatoes/popcorn, unlike some people think.
- Monitor for systemic symptoms: signs of infection–fever, malaise, etc.
- Monitor for abdominal pain
Diverticulitis can be dangerous bc they can rupture and lead to ______
Peritonitis.
Management of Diverticulitis:
- Colon rest
- Bed rest
- NPO or liquid diet
- NG tube if vomiting
- Antibiotics
- Pain management
- Some will require surgery
- Colon resection
- Temporary colostomy until healing
- Dietary modifications
- High Fiber Diet-regulates bowel function
- Water intake-Best if have 6-8 glasses of 8 oz of water per day
The part of the intestines that is important in the absorption of nutrients and fats:
ileum (small intestines)
The large intestine reabsorbs __&___
water and sodium
What will stool from an ileostomy look like?
semi-formed, liquidy/mushy
What are the benefits of a Kock Pouch over an Ileostomy?
Ileostomy has bag and KP doesn’t (internal pouch–will have feeling of fullness). Risk for skin breakdown with Ileostomy. Ileostomy is continually leaking and may have to empty it 4-5 times a day.
The Kock Pouch and J-pouch are contraindicated with _____
Crohn’s.
The J-Pouch is used for _____
Ulcerative Colitis.
How is the J-Pouch different from the Kock Pouch?
able to defecate thru rectum with J-Pouch.
Diarrhea is common after a Bowel Resection for ____ weeks.
6
What are some risks with a Bowel Resection?
Dumping Syndrome, Paralytic Ileus (distended abdomen, n/v, no bowel sounds/hypoactive), Anemia; decreased absorption of B12 & digestion of fat, glucose, and protein; Peritonitis; Peforation; F&E imbalance; hemorrhage; obstruction.
When do you irrigate an ileostomy?
NEVER!
When should you empty an ileostomy bag?
When it’s about 1/3 full.
Necrosis of a stoma is most common within the first ______
48-72 hours.
What type of meds should you avoid with an ileostomy?
Enteric-coated.
How much fluid should you drink when you have an ileostomy?
2-3 L: risk for dehydration bc of constant output
What diet recommendations should you give a person with an ileostomy?
LOW fiber; high protein/carb/calorie; supplement fat-soluble vitamins and b12; chew food well; lots of fluids.
What is the stool like with a J-Pouch?
loose bc colon is removed.
What can happen in 30% of patients with a J-Pouch?
Pouchitis.
What are some symptoms of Pouchitis?
pain in area, increase in diarrhea, bleeding, fatigue, fever, etc.
J-pouch carries a risk of possible _______
sexual dysfunction.
Risk factors for Colorectal Cancer:
*Personal or family hx of colorectal polyps or cancer
–Age consideration >50 y/o: everyone
–Genetic abnormalities have been identified
*Life style
–Obesity, smoking, ETOH
–High fat, low fiber diet (animal– red meat sources)
-Mediterranean diet best for us & veggies, whole wheat, etc
What is the Gold Standard screening for Colorectal Cancer?
Colonscopy!
What are the recommendations for colonoscopies for prevention of colorectal cancer?
–Colonoscopy Q 10years age 50 y/o, AA age 45
§If have 2 primary relatives (mother, father, sister, brother, but also think about 1st set of grandparents) with CRC before 60, begin screening at age 40
§Or 10 years before the dx was made in the family member (mom was diagnosed at 35, then you need to be screened at 25)
–repeat every 5 years if polyp is found
What are some screening methods for colorectal cancer other than colonscopy?
–FOBT (fecal occult blood test), DRE (check for low polyp in sigmoid) and Stool for DNA markers
–Double contrast BE (barrium enema)–what is this procedure, Flexible Sigmoidoscopy–while awake, stick tube up rectum into sigmoid, uncomfortable–might as well just get a colonoscopy
–Virtual colonoscopy: swallow pill and can see stuff
§What are the disadvantages ? Can’t remove anything during it
Clinical Manifestations of Colorectal Cancer:
*General changes
*Weight loss, weakness, anorexia, nausea, vomiting
*More specific
–Abdominal pain, cramping
–Palpable mass
*Change in stool size, color, frequency
§Left side vs. right side symptoms? Left side=change in shape/size; ribbon-like; more in left than right side
–Blood in stool
-May have constipation
Pre- and Post-op care for Bowel surgery:
–Pre-op: bowel prep (Go-Lightly or Magnesium Citrate); need to be able to see through the stool (should be clear pretty much); some people may have trouble with Go-Lightly so may have to get enema (nursing assistant can do regular cleansing enemas but we have to monitor the patient); Patient can get dizzy/pass out because they are depleted. If you send them down to endoscopy and they are not cleansed, MD will be pissed. Antibiotics for 24-48 hours beforehand.
–Post-op: give Versed, Morphine, etc; will be out of it; Monitor LOC and airway–put on left side (empties air and prevents cramping)–tell patients to pass gas even if they don’t want to; NG tube with suction until peristalsis returns; Rectal drainage (may need undies); monitor stoma (should be red and moist)–dark/dusky=call surgeon immediately.
With a double-barreled colostomy, the proximal end will have ___ coming out while the distal end will have ___ coming out. The ___ end may not even need a pouch and can be covered with a gauze dressing.
feces; mucous; distal.
___ colostomies are usually permanent while __ &___ ones are usually temporary.
Single-barrel; Double-barrel & Loop
