Week7 6671/6611 Flashcards
SBO- small bowel obstruction
Causes (common)
Adhesions
Hernias
Inflammatory diseases
Tumors
SBO - small bowel obstruction
S/S
Cramping and abdominal pain (5-15 min waves; centered on navel or between navel and rib cage) Nausea and vomiting No gas passing through the rectum Abdominal bloating Rapid pulse and rapid breathing Upper epigastric distention Constipation Lack of appetite
LBO- large bowel obstruction
Common causes
Colorectal cancer
Volvolus
Diverticular disease
In general obstruction of small intestine presents with ____, as ____ tends to be more large bowel obstruction.
Colicky abdominal pain and vomiting (SBO)
Distention and absolute constipation tend to be more common in large bowel obstruction
LBO- large bowel obstruction
S/S
Lower abdominal bloating/distention Lower abdominal cramping and pain Constipation Diarrhea Possible rectal bleeding
80% of bowel obstruction are ___
Large intestines (LBO)
In developed countries- usually from adhesions.
Volvolus
Twisting of bowel around itself
(LBO)
Most common >65 y/o w/ hx of chronic constipation
Red flags for immediate medical referral
Intense and/or constant abdominal pain
Vomiting
Bloating
Blood in the stool
GI system checklist
Swallowing difficulties
Indigestion/heartburn
Food intolerance
Nausea/Vomiting
Bowel dysfunction: Color of stool Shape, caliber of stool Diarrhea Difficulty initiating Incontinence
Causes of dysphagia
Muscle incoordination: Myasthenia gravis MS Amytrophic lateral sclerosis Parkinson’s
Mechanical obstruction: Tumors Thyroid goiter Osteophytes of c-spine Aortic aneurysm
Clinical manifestations of dysphagia- motor cause
Onset: gradual
Progression: slow
Equal difficulty w/ soft foods vs liquids
Worse swallowing cold substances
Bolus passage: repeated swallowing; valsalva maneuver, throwing back head and shoulders
Clinical manifestations of dysphagia- Mechanical cause
Onset: faster
Progression: faster
More difficulty swallowing solids than liquids
Swallowing difficulty not affected by temperature
Bolus passage: can be accompanied by regurgitation
Questions to ask about dyspepsia (indigestion/heartburn)
How long have you had symptoms?
Do you know what is causing?
Constant or intermittent?
How are you treating the symptoms?
Associated symptoms:
Fatigue
Weakness
SOB
Common food intolerances
Cheese Chocolate Citrus Nuts Red wine
Can be warning sign for underlying pathology - ie gallbladder
Melena (GI bleeding- dark)
Questions to ask
How long have you been having black, tarry stools?
Have you felt lightheaded?
Have you had any nausea, vomiting, diarrhea, fatigue, abdominal or back pain, or sweats associated with these stools?
Obstructive jaundice
Questions to ask
How long have you noticed the light, pale-colored stools?
Have you noticed an atypical color (ie dark) of urine?
Have you noticed any associated symptoms such as fatigue, fever, chills, unexplained weight changes or nausea?
Hematochezia (red blood stools) questions to ask
How long have you noticed bright red blood in your stool?
Is the red blood mixed within the stools (red streaks) or not?
Are there any associated symptoms, such as difficulty in initiating bowel movements or feeling of lightheadedness or fatigue?
“Have you noticed any unusual shape of your stool recently, such as pencil-like in diameter, flat and ribbon-like?”
Question is asking about?
Colon carcinoma
Potential causes of constipation
Impaired mobility Inadequate dietary fiber Inactivity Diverticulitis Hypothyroidism Hypercalcemia Scleroderma Neurologic dysfunction MS SCI Psychosocial dysfunction Depression/Anxiety Situational stress
Potential causes- diarrhea
Infectious agents Laxative abuse Colon cancer Irritable bowel syndrome Crohn’s Ulcerative colitis Diabetic enteropathy
Diarrhea questions to ask
How many episodes each day?
How long gave you gas diarrhea?
Do you ever have periods of diarrhea alternating with periods of constipation?
Is diarrhea worse at certain times of day?
Do family members or companions have similar symptoms?
Do you have any associated symptoms such as fever, chills, nausea, vomiting, confusion or abdominal pain or distention?
S/S of dehydration
Thirst and dry mouth Postural hypotension Rapid breathing Rapid pulse (>100 bpm) Confusion, irritability, lethargy HA
Hematuria
And questions to ask
Blood in urine
How long have you noticed red urine?
Do you have a hx of bleeding problems?
What medications are you currently taking?
Do you currently have, or have you recently recovered from an upper respiratory infection or sore throat?
ED can be associated with
SCI Herniated disk Post surgical complications: radical prostate, bladder, colon procedures DM Medication side effects Psychogenic disorders
Causes of bowel obstruction
Mechanical:
Adhesions
Hernias
Tumors
Other: Diverticulitis Foreign bodies Intussusception Fecal impaction
Also consider: Ogilvie syndrome; Post-op ileus
About __% of partial bowel obstructions resolve without operative tx
About __% of complete bowel obstructions require surgery
85%
85%
Suspicion of bowel obstruction requires?
Hospitalization
Bowel resection
AKA partial colectomy
Can be open or laparoscopic
Obstruction, Cancer, Crohn’s, diverticulitis, severe bleeding
Sometimes colostomy needed
Colostomy
Surgical procedure bringing portion of the large intestine through the abdominal wall to allow passage of bowel material out of the body as an alternative to the anus
Reasons for colostomy
Treat various large intestine disorder (cancer, obstruction, IBS, ruptured diverticulum, ischemia)
Can be temp to divert stool from injured/diseased section of large intestine
Can be permanent when distal bowel removed or blocked or inoperable (ie colorectal ca)
3 types of colostomy
- End colostomy- usually permanent
- Double barrel colostomy- usually temp
- Loop colostomy- usually temp
Stoma
External opening of the colostomy
Made by bringing end of intestine through an opening in abdomen and attaching it to the skin
Serves as connection for removable external collection pouch (ostomy appliance)
Colostomy post-op care
NG tube w/ low to intermittent suction until bowel activity returns
Stoma monitored w/in 72 hrs passage of stool begins
Diet (advanced as stoma becomes active)
Psychological consult
ERAS
D/C home 2-4 days depending on pain and GI activity; Possible return in 3-6 mo for colostomy “take down”
PT implications- post-colostomy
Activity restrictions:
No driving, heavy lifting 2-3 weeks
Avoid extreme physical exercise and sports for 3 mo
Eventually no activity restrictions, except maybe contact sports
Swimming is fine and encouraged.
BMI
< 18.5 underweight
18.5-24.9 normal weight
25-29.9 overweight
30-34.9 obese-1
35-39.9 obese-2
40 and < morbidly obese
Waist circumference
Obesity
Men > 40”
Women > 35”
Increased risk of heart disease and DM2
Bariatric
Branch of medicine that deals with causes, prevention and tx of obesity
Clinical manifestations of obesity: Increased risk of…
CV disease DM Stroke Arthritis Gallbladder disease Respiratory conditions Cancers
Metabolic syndrome
Group of conditions that lead to development of CV disease and DM2
Primary risk factors:
Abdominal (central obesity)
Insulin resistance
Metabolic syndrome - Dx
Dx with 3/5 conditions met
1. Waist circumference M > 40” F>35”
- Fasting glucose 100 mg/dL or use of meds for hyperglycemia
- Triglycerides > or = 150 mg/dL
- BP > or = 130/85 or use of HTN meds
- HDL M<40 mg/dL F<50 mg/dL
Wight distribution
Apple:
Apple pannus- inferior abdominal drift of adipose
Apple ascites- large abdomen, don’t tolerate lying flat
Pear: (Mostly in F)
Pear ABD- more weight hips/butt downward, tends to have knee valgus
Pear ADD- tends to have knee varus
Gluteal shelf- large gluteal mass of adipose
Mobilizing obese
Transfer sheets, overhead grab bar or trapeze, bariatric gait belts, other bariatric equipment
Spend more time planning than doing
Include pt in decision making
Number of people needed - consider 2-3 at most
Normal/Standard medical equipment is usually rated for about ____.
Bariatric equipment for ___.
250-300 lb max
Bariatric equipment rates for over 300 lbs
Mobilizing/Positioning -
Apple ascites obese
Little tolerance for supine or prone
Positioning
Supine -> Sit: flat spin with a sheet
Mobilizing/Positioning -
Apple pannus obese
Variability with supine tolerance
Supine -> Sit: Flat spine w/ sheet or prone flat spin w/ UE push up to stand
Mobilizing/Positioning -
Pear obese
Supine -> Sit: via long sitting to raise head of bed and use sheet to assist to EOB
Gait belt grips - obese
Thumb grip:
Face pt, cross arms, hand under belt from top palm out, bring 2 fingers to thumb,
Control slack w wrist flexion, radial deviation, elbow flexion
Twist grip:
Pt side, hand down into belt palm to back, twist toward thumb, control slack w wrist flexion, radial deviation, elbow flexion
Egress test
Sage to ambulate w/ bariatric pt
- Ask pt to lift bottom off surface as if going to stand (1-2 inch clearance) then return to sitting
- Ask pt to come all the way up to standing and bear weight on both LE 2x
- Ask pt to perform 3 reps of March in place
- Ask pt to take 1 step forward and then return to start position. Do this bilaterally.
Bariatric- exercise rx
Goals
Pt centered- behavior modification (not always weight related)
Weight loss 10% at 1-2 lbs a week
Increase physical activity to reduce risk of obesity related disease- aim for up to 1 hour moderate intensity 5x/week
Abdominal pain of MSK origin question clusters
cluster 1:
- Does coughing, sneezing, or taking a deep breath make your pain feel worse? (Yes)
- Do activities such as bending, sitting, twisting, lifting, or turning over in bed make you pain feel worse? (Yes)
- Has there been a change in your bowel habit since the start of your symptoms? (No)
Answering “yes” either to Q1 or Q2, and “no” to Q3 = moderate probability is MSK in origin
Cluster 2:
- Does eating certain foods make your pain feel worse? (No)
- Has your weight changed since your symptoms started? (No)
The probability increases to strong if both “no”
Abdominal pain of MSK origin may present as
Sharp and focal, cramping and aching, or deep.
In comparison, pain from visceral is often dull, aching, cramping, burning, gnawing, wave-like and poorly localized
Both can present with nausea
