WEEK 5 Flashcards
peptic ulcer disease : what is it ?
a condition characterized by erosion of the gastric or duodenal mucosa
the mucosal barrier is broken and HCL enters the tissues causing injury to the tissues
why does PUD happen ?
can be precipitated by what ?
drugs
stress
bacteria ( H. pylori )
just read : gastric ulcer vs duodenal
Gastric
* Peak at age 50-70 years
* Pain can be aggravated by food
* May be malnourished
* N or decreased gastric secretion
* Pain 30-60 min after a meal
* Heals with tx -if it recurs it is in the same location
Duodenal
* Peak at age 20-50 years.
* Pain relief with antacid and food. * Usually well nourished.
* Increased Gastric secretions
* Pain 1 1⁄2-3 hrs after meal
* Often has remissions and
exacerbations
yes
recognize cues : assessment diagnostic tests
explain it
pt hx
lab assesments
esophagogastroduodenoscopy
nuclear medicine scan
what are the complications of PUD
explain it
hemorrhage/upper gi bleed
perforation
gastric outlet obstruction
GI bleed
can be apply to a patient that comes in for a GI bleed that perhaps is not as a result of an ulcer as well. so you can apply what you learn here to any patient that comes in with a GI bleed
yes
what are the recognize cues: assessment
if the blood has not hit the stomach acid yet, then it is bright red
and vomiting lots of bright red blood
what undergoes it
- Hematemesis/ coffee ground emesis
- Tarry black stool (bleed from higher up/longer duration) - higher up intestinal bleed
- Abdominal pain
- Can proceed to shock
take action : stabilize patient ( upper GI bleed )
- Treat like for hypovolemic shock
- Calm approach, frequent VS, O2,
- IV fluids +++ (monitor for fld overload)
- I&O, monitor urine output
- Monitor stools/emesis
- Monitor lab work
upper GI bleed : take action : stop the bleed
explain each and everything
endoscopic therapy ( primary treatment procedure )
surgery
drug therapy
antacids, PPIs, h2 receptor blockers
helpful decreases the irritants and help that bleed stop
what is octreotide ( sandostatin )
used to decrease blood flow to the abdominal organs it causes phases
constriction of vessels and its given IV over five to six days after the initial bleed
and helps with that bleed helps that bleed to stop
true or false. vasopressin , causes vasoontriction but vasopressin we have to watch carefully because it can also contrict all other vessels
so it needs to be given with caution and that pt needs to be monitored
true
perforation is the spillage of gastric contents into peritoneal cavity
this is where stomach mucosa erose away until theres a whole in the stomach
it spill into the peritoneal cavity
recognize cues : what undergoes perforation
Sudden severe abdominal pain
* rigid board like abdomen
* pain
* increasing distention
what undergoes take action for perforation
- Monitor for hypovolemic and /or septic shock and treat
- Maintain NG for gastric decompression
- Antibiotic therapy
- Prepare for surgery
what is the contraindication if mucosa is perorated , what should the nurse not do ?
is put anything down that ng tube
because whatever goes down that stomach is just going to spill out into the peritoneal cavity
just read : complication of pud : gastric outlet obstruction
Gastric Outlet Obstruction
* Narrowing of pylorus from…
Recognize Cues
* Pain that progresses and becomes
* Swelling of upper abdomen
* Projectile vomiting
* undigested particles from hours or days ago
Take Action
* Decompress with NG tube
* IV fluid and electrolyte replacement
* Surgery to open obstruction and remove scar tissue
trueeee
PUD pharmacological therapy
HAPCA
h2 receptors
antacids
PPIs
cytoprotective
antibiotics for H pylori
just read for the discharge planning for PUD :
Discharge Teaching of PUD: Conservative Therapy
* Dietary Modifications
* Avoid spicy foods, acidic foods, caffeine, alcohol
* Stop Smoking
* Avoid OTC Meds
* Take all meds as prescribed
* Report bloody emesis, tarry stools, increased epigastric pain
* Encourage patient to share concerns about following lifestyle changes
explain what pud surgical procedures are
billroth I
billroth II
vagotomy
pyloroplasty
- Billroth I: Gastroduodenostomy
- Partial gastrectomy with removal of distal
2/3 stomach and anastomosis of gastric stump to duodenum. Antrum and pylorus removed. - Billroth II: Gastrojejunostomy
- Partial gastrectomy with removal of distal 2/3
stomach and anastomosis of gastric stump to Jejunum. Antrum and pylorus removed. - Vagotomy
- Severing of the vagus nerve
- Eliminates the stimulus to secrete HCL
- Pyloroplasty
- Surgical enlargement of the pyloric sphincte
Take Action:Post-op care after surgery for PUD
just read :
* Will have NG to decompress stomach
* Monitor bowel sounds
* Monitor N/G content (color and amounts)
* Ensure patency of NG tube
* Remove NG tube when peristalsis returns
* IV fluids with K+ and vitamin replacement
* Introduce foods when ordered
* Care of abdominal incision
* Encourage DB&C with splinting
* Encourage ambulation to increase peristalsis
explain ensure patency of ng tube
may need saline irregations every 4 hours
if the tube plugs and the stomach becomes distended this could cause rupture of the suture lines and leakage of the gastric contents of peritoneal cavity
why is there pernicious anemia ?
when we remove so much of the stomach and the bowel were losing a lot of parietal cells
where the intrinsic factor is produced , we need that intrinsic factor b12 and b12 is needed to synthesize hemoglobin needed to synthesize hemoglobin so this patients ends up with pernicious anemia
true or false. putting up pillow against their stomach while they’re doing their deep breathing and coughing really helps them when it comes down for surgery pud
true
post op complications for billroth I and billroth II
dumping syndrome
post prandial hypoglycemia
bile reflux gastritis
what is the variant of dumping syndrome ?
postprandial hypoglycemia
what is this describing
; Hyperglycemia releases insulin resulting in secondary hypoglycemia.
post prandial hypoglycemia
gastric cancer :
recognize cues
- Anemia
- Vague epigastric fullness
- feelings of early satiety after meal
- weight loss, dysphagia, dyspepsia
true or false. * During an endoscopic ultrasound can be performed to evaluate
depth of tumor and presence of lymph nodes
true
true or false. If in early stages laparoscopic surgery may be all that is needed however in late stages a total gastrectomy may be required.
true
Total Gastrectomy with Esophagojejunostomy (removal of stomach with resection of esophagus to jejunum)
- will have N/G (drainage minimal)
- will have chest tubes because enter through chest wall.
- Clear fluids initiated after several days to solid foods
- Radiation/ chemotherapy to adjunct or if surgery is not an option
- At risk for poor nutritional status, wt loss, vitamin
deficiency, pernicious anemia, dumping syndrome, postprandial hypoglycemia : is this true or false when it comes down to surgical management of gastric cancer
true
what are the two autoimmune disorders of GI tract
ulcerative collitis
crohn’s
recognize cues : ulcerative collitis
- Peaks between the ages of 15 & 25
- Bloody diarrhea
- Abdominal pain
- Located distally in the rectum and spreads proximally in a continuous fashion of the colon
- Cured with Surgery
recognize cues : crohn’s disease
- Peaks between the ages of 15 & 30
- Non-bloody diarrhea
- Abdominal pain
- Can occur any where in the colon from mouth to anus (most often in the ilium)
true or false. ulcerative collitis, gone for good in the bowel when it comes to surgery
true
crohn’s disease, reoccurrence after surgery
more lessions may form multiple surgeries ( less and less bowel to work with )
Recognize Cues: Intra-intestinal complications of IBD
ulcerative collitis
hemorrhage
perforation
colonic dilation
colorectal cancer
this is an extensive dilation and paralysis of the colon
toxic megacolon
true or false. If they have UC for greater than 10 years, the pt is at risk
true
often associated with the deep longitudinal ulcers
that penetrate in this inflamed mucosa and it looks like kind a cobble stone appearance
this is crohn’s disease
what undergoes intra intestinal complications of IBD: recognize cues
- Stricture, obstruction
Perforation, intra-abdominal abscess
Malabsorption ,
Fistulas (Cardinal feature)
- Stricture, obstruction
- May communicate with loops
of bowel, vagina, urinary
tract causing feces in urine
and UT
what are the extra intestinal complications of ulcerative colitis and crohn’s
anthroplasty
arthritis
ocular manifestations
ostepenia./osteoporosis
skin manifestations
thromboembolic events
take action for acute phase : uc and crohns
**Frequency, amount and color of stools most important to monitor because the severity of diarrhea
determines how much fluid replacement is necessary **
what should be utilized ?
nutrition and fluid an electrolyte balance
daily wts
meticulous perianal care
what should u monitor during acute phase of uc and crohn’s for taking action
dehydration
fatigue
skin breakdown
ineffective coping strategies
intra/extra intestinal complications
blood in stools
take action for maintenance phase ( uc and crohn’s)
chronic/long term disease … remissions and exacerbations
what are the maintenance drugs
C
I
I
V
A
- ***5-ASA-Sulphasalazine–longterm(worksbestinlargeintestinetodecreaseinflammation)
- Corticosteroid Drugs -prednisone
- Immunosuppressant’s–cyclosporine(Neoral)
- Immunomodulators-infliximab(Remicade)
- Vitamins- oral iron (ferrous gluconate), IV iron (iron dextran)
- Antidiarrheal-diphenoxylate (Lomotil)
diet : maintenance phase ( uc and crohns )
- Avoid triggers -Need a food diary
- Often avoid dairy –(but ok in moderation)
*Eat high Calorie, high protein low fat - Nutritional supplements
- Low residue diet
Take Action: UC surgery
Total proctocolectomy (with permanent ileostomy)
is a one stage operation involving the removal of the colon, rectum, anus with the closure of the anus.
- The end of the terminal ileum is brought out through the abdominal wall and forms a stoma, or stoma.
- The stoma is usually placed in the right lower quadrant of the rectus muscle.
- Colostomy bag at all times
Take Action: UC surgery
Total proctocolectomy - ileoanal reservoir (pelvic pouch) and anal anastomosis
Can be staged depending on pre-op health of patient.
- First colectomy with temporary ileostomy (while pt restores health and improves
status) - Next takedown of ileostomy, ileoanal reservoir created from small bowel and attached to anus.
- Results in 6-8 pasty stools/day and good daytime continence
what is the post ip care after proctolectomy with permanent ileostomy or ileonanal resorvoir
- Stoma care
- Dressings/packings
- Expected tubes/ drains
- N/G
- Stool amount/type/frequency
- Anal sphincter control (if have a reservoir) * Kegel exercises
- Nutrition/Diet
bowel obstruction , can be partial or complete obstruction of the intestine
yes
where can bowel obstruction occur ?
- Small bowel * Large bowel
how does bowel obstruction happen
hernia
adhesions
paralytic ileus
cancer
anything that blocks
true or false. purturdes through the muscle
blocking stool that moving forward can cause obstruction
true
recognize cues : assessments
what is the difference between LBO and SBO
start with SBO
rapid onset
frequently vomiting
colicky intermittent
abd pai
bm for short pain
mild/moderate distention
recognize cues : assesments what is the difference between lbo and sbo
what is the LBO
gradual onset
vomiting in late stages
low grade cramping
constipation
significant abd distention
this is higher up so whatever stool is below that is still
may pass through so they may actually have bowel movements for short time
where is this occuring
SBO
bowel obstruction “ recognize cues : diagnostics
abd xray, ct ( show gas and fluid in intestines )
interventions: take action for bowel obstruction
decompression of ng
abd assesments
pain assesments
n/g care
nutrition/fluid/lytes replacement
prepare for surgery if not resolved
monitor for perforation
what is colorectal cancer
malignant disease of colon rectum or both
symptoms not often seen until late stages
what are u assessing for when it comes to colorectal cancer
change in elimination habits
change in consistency, shape
gas pains/rectal pain not usual
blood in stools
diagnostic tests for colorectal cancer
fobt, family history, colonscopy, dre, cea, ct, u/s1
what are the risk factors for colorectal cancer
alcohol use for to six drinks a day
if the pts greater than 50, if they have history of irritable bowel disease
genetic cause and what they eat
what are the clini mani for colorectal cancer
bleeding diarrhea, or ribbon like stool if the tumour is blocking
current recommendations for screening in canada?
if low risk fobt or fit every 2 years after turning 50
if results positive then go for colonscopy
if high risk start earlier than 5o and start with colonoscopy
Recognize Cues: Diagnostics Colonoscopy
- used to diagnose
- take biopsy
- remove polyps
pretty sedated to a time and they wont be going to play any sports, thats for sure
for colonscopy
true
Take Action:
Surgical Management for colon cancer
if they do have colon cancer surgery is the only treatment for it
what is it
Remove section of bowel with the tumor and reanastomosis (reconnect) ends
what is right hemicolectomy
is performed when the cancer is located in the cecum, ascending colon, hepatic flexure and transverse colon
what is left hemicolectomy
involves resection of left transvere colon, splenic flexor and descending colon, sigmoid colon and upper portion of the rectum
remove section of bowel with the tumor and reanastomosis ends
take action : abdominal peritoneal ( AP ) resection
performed when the cancer is located within 5 cm of the anus
distal sigmoid colon, rectum and anus removed
proximal sigmoid brought through abdominal wall
permament colostomy
take action : abdominal peritoneal ( AP ) resection
two wounds and a colostomy after AP resection
abd incision
perineal incision is sewn closed with drain in place or packed and left open
where the colostomy located in two wounds and a colostomy after AP resection
colostomy stoma in LLQ
take action : abd peritoneal resection
Potential Complications
delay wound healing and infections
urinary incontinence and sexual dysfunction
take action : post op care specific to ap resection
careful wound assessment and care and positioning
careful wound assessment and care
post op care specific to ap resection
abdominal and perineal incisions and colostomy
keep perineum clean and dry ( irrigate with NS )
dressing changes
drain care
positioning for post op care specific to AP resection
side to side positioning
pressure cushion if sitting
no pressure on perineum
the pt will probably go home with how to keep that area clean and the dressing care the dressing
changes or care of the wound
true
ostomy
is a surgical opening of the intestine to permit diversion of fecal material
what are the types of ileostomy
colostomy
— ileum brought in the abdomen
depending on the location : the higher up where the ostomy is, that means there is less absorption of fluid taking place
for ex: ileostomy ( removed most of the colon ) that stool in the ostomy bag will
be very liquidy
colostomy - that stool is normal looking, pt can sometimes time it
dont have to wear big bag
just read
Recognize Cues -Stoma Assessment
assess stoma q8h. expect to see :
mild to moderate edema
small amount bleeding, oozing when touched
amount of drainage in the first 24-48 hrs negligible
true or false. With stoma assessment, will begin to pass flatus as peristalsis increases ( 4h hrs )
true, yes this will increase ( expect it )
Discharge Teaching: Colostomy & Ileostomy care
teach the following
- inspect stoma and skin for breakdown
- empty pouch when 1/3 full or inflated with gas
- Deodorants as needed
- Avoid food that cause odor gas, diarrhea or obstruction
- Initially low residue diet then increase gradually
what are the examples of food to avoid because it causes gas , diarrhea, obstruction
onions, garlic, eggs, and all odor producing gas forming
popcorn, nuts, raisins , potential obstructors in the ostomy
discharge teaching : colostomy and ileostomy care
Increase fluid intake and observe for S&S of dehydration
- Assess stool consistency (liquid for ileostomy, formed for sigmoidoscopy)
- Support groups for emotional adjustment
- Follow up care Report S&S of
——- Fever, diarrhea, constipation, other stoma problems
Rules that apply to all GI surgery post-op
pain control, nausea, constipation
what undergoes pain control
pca or regular analgesia for 72 hrs
splint incision with db & c
position for comfort/ambulate to relieve gas pains
what undergoes nausea
antiemetics
ng to low suction
assesses bowel sounds/and distention
eliminate unpleasant sights smells and stimuli
what undergoes constipation
assess for distention and bowel sounds q shift
ambulation as tolerated
stool softeners or antidiarrheals
increase fluid intake
true or false dehydration is rlly a risk factor for these ppl so watch out for that when it comes down to gi surgery post op
true
recognize cues : assessment : diverticular disease
what is diverticulosis
presence of multiple non inflamed diverticula ( outpounchings ). pt is asymptomatic
except may have crampy pain, constipation, or diarrhea
what is diverticulitis
inflammation of the diverticula due retention of stool in the outpounchings
forms a fecalith ( hard mass )
true or false. inflammation spreads to surrounding tissues. what can diverticulitis cause?
edema, abscesses, perforations, peritonitis
what will we see in diverticulitis ?
abd pain over invovled area
where would the tender be in diverticulitis and what are the s and s
tender lower left quadrant mass
s and s infection ( fever, chills, nausea, anorexia, elevated wbcs)
what are the diagnostics of diverticular disease
ultrasound or ct scan
interventions :take action diverticular disease
complications
abscess
bleeding
bowel obstruction
perforation with peritonitis
fistula formation
ureteral obstruction
treatment for take action : diverticular disease
monitor for infection
rest the bowel - npo with iv fluid
low fiber diets for mild flare ups
iv fluids and A/B for severe symptoms
surgery
recognize cues : assessment hernia
what is it ?
protusion of viscus ( usually intestines or tissue )
what is this describing : Protrusion of a viscus (usually intestines or tissue) through an abdominal opening or weakened area in the wall of the cavity in which it is normally contained
hernia
what are the different types of hernia
inguinal, femoral, umbilical, incisional
what will you see in hernia
pain to area of hernia
if can be placed back into abd cavity, it is reducible
what will happen if strangulated can have s and s of bowel obstruction :
hernia, and this is a surgical emergency
interventions : take actions hernia
what are they ?
watchful waiting
herniorrhaphy
hernioplasty
post op care
what is watchful waiting for hernia ?
may wear truss ( live with a hernia, lay down and reduce it back it ) hold everything in place.
herniorrphaphy what is it ?
surgical repair of hernia
hernioplasty
surgical reinforcement of the weakened area with a fascia or mesh
what is the post op care for herniorrphy, hernioplasty
observe for bladder distension
- Accurate input and output
- Scrotal support may help relieve discomfort.
- Coughing is not encouraged, but deep breathing and turning should be done.
- Splint incision.
- Position appropriately (decrease pressure in suture line).
Ano-rectal conditions : Hemorrhoids
what is it ?
varicosities in the lower rectum or the anus caused by congestion in the veins
what are the cause of ano-rectal conditions : hemorrhoids
pregnancy
prolonged constipation
portal hypertension
prolong standing and sitting
heavy lifting
straining to defecate
prolonger constipation and straining to defecate causes what ?
straining a lot of pressure
what are the collaborative care : ano-rectal conditions : hemorrhoids
band ligation ( put a rubber band and lower instrument deploys on the hemorrhoids and falls off )
cryotherapy, laser treatment ( freezing of the hemorrhoids and falls off )
high fibre diet ( to prevent constipation )
increased fluid intake
surgical excision
hemorrhoidectomy ( surgical incision of the hemorrhoids )
Discharge Teaching after Hemorrhoidectomy
- Narcotics for Sphincter Spasm
- Sitz Bath 1-2 days post surgery
- Dressing change/packing
recall that we already know to teach the pt about hemorrhoidectomy :
- Narcotics for Sphincter Spasm
- Sitz Bath 1-2 days post surgery
- Dressing change/packing
- Stool Softeners -docusate sodium (Colace)
- Analgesics before bowel movement
true or false. they will have dressing with hemorrhoidectomy and keep it clean
true
what is sitz bath ?
warm water and swirls ( and cleans the area )
