TEST 2 MOD 11 WINKS Flashcards
Care of the patient with infectious diarrhea (esp. C. diff)
Contact precautions
Hand washing
Description of stool, frequency, associated symptoms
Assess for clinical manifestations of dehydration
Abdominal exam
Stool studies
Blood, mucus, WBCs, parasites
Culture to identify organism
C. difficile identified by measurement of its toxins (toxin A & B)
Care of the patient with fecal incontinence
Etiology and Pathophysiology
Motor function
Obstetric trauma
Childbirth, aging, menopause
Fecal impaction
Damage from anorectal surgery
Sensory function
Neurologic conditions
Diabetic neuropathy
Decreased LOC
Motor: contraction of the sphincters and rectal floor muscles
Sensory: ability to perceive the presence of stool or to experience the urge to defecate
Neuro: stroke, SCI, MS, Parkinson’s
Requires sensitivity
H & P
Rectal exam
Abdominal x-ray
A rectal examination can reveal reduced anal canal muscle tone and contraction strength of the external sphincter, as well as detect internal prolapse, rectocele, hemorrhoids, masses, and fecal impaction.
Other tests, such as anorectal manometry, anorectal ultrasonography, and anal electromyography, are done when symptoms persist after treating underlying problems or certain problems need further evaluation.
Fecal incontinence from fecal impaction usually resolves after manual removal of the hard feces and cleansing enemas.
Regardless of the cause of fecal incontinence, bowel training is effective for many patients. Bowel elimination occurs at regular intervals in most people. Knowing the patient’s usual bowel pattern can help you plan a bowel program that will achieve optimal stool consistency and establish predictable bowel elimination patterns. For the hospitalized patient, placement on a bedpan, help to a bedside commode, or walks to the bathroom at a regular time daily help to establish regular defecation. The best time to schedule elimination is within 30 minutes after breakfast.
Perform frequent skin assessments when using absorbent products. Incontinence pads are an option when the patient is in bed. Briefs should be used only during ambulation or when sitting in a chair. Make sure they are changed promptly after each episode of incontinence.
Cleanse the skin gently, using a skin cleanser rather than soap and water. Pat the skin dry or use a blow dryer on a cool setting. Do not rub the skin dry. Apply a moisture barrier and, if needed, a skin barrier cream for more protection.
Constipation: Nonpharmacological treatments/prevention.
Diet is a key factor in preventing and treating constipation. Many patients have improved symptoms when they increase their dietary fiber intake. Dietary fiber is found in fruits, vegetables, and grains. Wheat bran and prunes are especially effective for preventing and treating constipation. Whole wheat and bran are high in insoluble fiber. Dietary fiber adds to the stool bulk directly by attracting water. Adequate fluid intake (2 L/day) is essential. Large, bulky stools move through the colon much more quickly than small stools. However, the recommended fluid intake may be contraindicated in a patient with heart disease or renal failure. Tell the patient that increasing fiber intake may initially increase gas production because of fermentation in the colon, but this effect decreases over several days.
Patient teaching
Dietary fiber
Fluids
Exercise
Establish regular time to defecate
Don’t delay defecation
Record bowel elimination pattern
Avoid laxatives and enemas
Constipation: medications generally used for prevention
can be taken daily
Bulk-forming laxatives
Methylcellulose (Citrucel), Psyllium (Metamucil)
Stool softeners
Docusate (Colace)
Saline and osmotic solutions
Polyethylene glycol (Miralax)
Stimulants
Senna (Senokot)
Bulk forming laxatives
Absorbs water, increases bulk—stimulating peristalsis
Usually acts in 24 hours
Stool softeners and lubricants
Lubricate intestinal tract and soften feces (makes it easier to pass)
Does not stimulate peristalsis
Lubricants act in 8 hrs; softeners act in 72 hours
Saline and Osmotic solutions:
Watch Magnesium levels *esp. in those w/ renal impairment
Cause retention of fluid in intestinal lumen caused by osmotic effect; act in 15 min to 3 hrs
Stimulants
Increase peristalsis by irritating the colon wall and stimulating enteric nerves
Usually act w/in 12 hours
Assess for last BM, characteristics before administration!
Constipation: medications generally used for first-line treatments
Should only be taken as needed
*Can cause dependence
Stool lubricants
Mineral Oil Enema (Fleet’s)
Saline and osmotic solutions
Magnesium citrate, milk of magnesia
Lactulose (Chronulac)
Stimulants
Bisacodyl (Dulcolax)
Nursing and collaborative management of diverticulosis
Diverticula are saccular dilations or outpouchings of the mucosa that develop in the colon.
Diverticula vary in diameter from 1/10 inch to 1 inch (about ¼ to 2½ centimeters). They are uncommon before age 40 but become more common rapidly thereafter. Just about everyone who reaches age 90 has many diverticula. Giant diverticula, which are rare, range from 1 to 6 inches (about 2½ to 15 centimeters) in diameter. A person may have only a single giant diverticulum.
Diverticulosis is the presence of multiple noninflamed diverticula.
Common to have no symptoms
Discovered during routine colonoscopy
Other symptoms
Abdominal pain
Bloating
Flatulence
Change in bowel habits
Blood in stool
collaborative management of diverticulitis
Diverticulitis is inflammation of 1 or more diverticula, resulting in perforation into the peritoneum. Diverticula may occur anywhere in the GI tract but are most common in the left (descending, sigmoid) colon. The main contributing factors are thought to be constipation and a lack of dietary fiber. Other risk factors are obesity, inactivity, smoking, excess alcohol use, and NSAID use.
Left lower quadrant abdominal pain (sigmoid colon)
Elevated temperature
Leukocytosis
Palpable abdominal mass
Older adults with diverticulitis may be afebrile, with a normal WBC count and little, if any, abdominal tenderness.
Diverticulitis can cause erosion of the bowel wall and perforation into the peritoneum. A localized abscess develops when the body walls off the perforated area. Peritonitis develops if it cannot be contained.
Perforation w/ peritonitis: infection of the lining of the abdominal cavity (peritonitis). If a diverticulum ruptures, the contents of the intestine, including bacteria and blood, spill into the abdominal cavity, often causing infection.
Fistula formation: An abnormal channel (fistula) may form between the large intestine and another organ, usually when a diverticulum that touches another organ ruptures.
Bleeding: In diverticular disease, a diverticulum may bleed into the intestine.
Bleeding can be extensive but stops spontaneouslyIn acute diverticulitis, the goal of treatment is to let the colon rest and the inflammation subside. Some patients can be managed at home with a clear liquid diet, bed rest, and analgesics. Hospitalization is needed if symptoms are severe, the patient is unable to tolerate oral fluids, there are systemic manifestations of infection (fever, significant leukocytosis), or the patient has co-morbid conditions (e.g., immunosuppression).
Patients with reoccurring diverticulitis or complications, such as an abscess or obstruction, may need surgery. The usual surgical procedure involves resection of the involved colon with a primary anastomosis. If the HCP is not able to anastomose the colon, the patient will have a temporary diverting colostomy. After the colon heals, the temporary colostomy can be taken down and the ends of the colon reconnected.
Reserved for patients w/ complications such as abscess or obstructions that can’t be managed medically.
About 80% of people can be treated without surgery. An abscess is drained with a needle inserted through the skin and guided by a CT scan. If drainage helps, people remain in the hospital until symptoms have been relieved and they have resumed a soft diet.
Emergency surgery is necessary for people whose intestine has ruptured, or who have peritonitis and for people with severe symptoms that do not respond to nonsurgical treatment within 48 hours. People who have increasing pain, tenderness, and fever also need surgery.
Intestinal rupture always results in infection of the abdominal cavity. The surgeon removes the ruptured section of the intestine. The ends are rejoined immediately in healthy people who do not have a perforation, abscess, or severe inflammation. Other people need a temporary colostomy. About 10 to 12 weeks later (or sometimes longer), after the inflammation has gone away and the person’s condition has improved, the cut ends of the intestine are rejoined during a follow-up operation, and the colostomy is closed.
Treatment of a fistula involves removing the section of large intestine where the fistula begins, rejoining the cut ends of the large intestine, and repairing the other affected area (for example, the bladder or small intestine).
UTI clinical manifestations, diagnostic tests, treatments, nursing interventions
pyelonephritis clinical manifestations, diagnostic tests, treatments, nursing interventions
what is different in pyelonephritis vs. UTI
Upper urinary tract: Pyelonephritis (Kidney)
Lower urinary tract
Cystitis (Bladder)
Urethritis (Urethra)
Types of incontinence and treatments
Stress Incontinence
Involuntary loss of urine during activities that increase abdominal and detrusor (bladder muscle) pressure
Urge Incontinence
Involuntary loss of urine associated with a strong urge to urinate
Overflow Incontinence
Involuntary loss of urine associated with over-distention of the bladder when bladder capacity has reached its maximum due to urethral obstruction/spasm
Reflex Incontinence
Involuntary loss of urine that occurs without warning
Associated w/ CNS disorders
Functional Incontinence
Loss of urine resulting from cognitive, functional, or environmental factors
Criteria for straight vs. indwelling urinary catheters
Indwelling catheter
Urinary retention
Bladder decompression before or after lower abdominal or pelvic surgery
Genitourinary surgery
Accurate measurement of I/O in critically ill patients
To prevent contamination of stage III or IV pressure ulcers
Terminal illness, when positioning is associated w/ significant discomfort
Straight (in and out) catheter
Study of anatomic structures of urinary system
Urodynamic testing
Collection of sterile specimens in selected situations
Instillation of medications into the bladder
Measurement of residual urine after urination (post void residual-PVR) if portable ultrasound is not available
BPH: meds
alpha blockers:
*Alpha Blockers
-Blocks the α1-adrenergic receptors in the prostate smooth muscle to improve urinary flow
-May cause orthostatic hypotension
Examples:
Silodosin (Rapaflo)
Alfuzosin (Uroxatral)
Terazosin (Hytrin)
- Doxazosin (Cardura)
Tamsulosin (Flomax)
Prazosin (Minipress)
Improvement in days to 2-3 weeks (50-60%)
Other SE: Retrograde ejaculation (semen is redirected to urinary bladder—bladder sphincter doesn’t contract before ejaculation), nasal congestion, and dizziness
Also used for HTN
The medications do not treat hyperplasia (helps w/ symptom mgmt.)
5alpha reductase inhibitors:
*5 alpha-Reducatase Inhibitors:
Finasteride (Proscar)
Reduces the size of the prostate gland to improve urine flow
Blocks the 5α-reductase isoenzyme (type 2), which is needed to convert testosterone to dihydroxytestosterone
Takes 4-6 months to be effective
Dutasteride (Avodart)
Same effect, dual inhibitor of 5α-reductase isoenzyme 1 and 2
SE: decreased libido, decreased volume of ejaculate, ED
Monitor liver function tests
Finasteride: (Proscar) to shrink the prostate and improve urine flow. Lowers levels of dihydrotestosterone (DHT) which is a major cause of prostate growth.
Risk of orthostasis w/ ED drugs
Can increase liver function tests
Women who may be or are pregnant should not handle tablets due to potential risk to male fetus (anomaly).
BPH:diagnosis, nursing interventions
Benign Prostatic Hyperplasia (BPH)
As men age, the glandular units in the prostate begin to undergo hyperplasia (abnormal increase in the number of cells), resulting in prostate enlargement (hypertrophy)
The enlargement causes narrowing of the urethra and results in partial or complete obstruction
Clinical Manifestations
Obstructive (due to urinary retention)
Difficulty initiating voiding
Changes in size and force of urinary stream
Dribbling at end of urination
Irritative (associated w/ inflammation and infection)
Urgency, frequency
Nocturia
Dysuria
Incontinence
Complications:
Acute urinary retention—requiring urinary catheter
UTIs
Calculi may develop b/c of alkalization of the residual urine
Hydronephrosis
Renal failure
Diagnostic Studies
Digital Rectal Exam (DRE)
To estimate size, symmetry, consistency of prostate gland
Additional tests depending on symptom severity
Urine culture
Prostate-specific antigen (PSA) blood test
Serum creatinine
Transrectal Ultrasound (TRUS)
TURP: post-operative care, expected findings post-operative, discharge instructions, and home care
