NU 350 Lower GI

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1

What are the characteristic s/s of irritable bowel syndrome (IBS)?

Intermittent and recurrent abd pain associated with alteration in bowel function

Abd distention

Altered bowel motility: Diarrhea or constipation, sometimes both

—Bloating

—Flatulence

—Urge to defecate

—Sensation of incomplete evacuation

Fatigue

Sleep disturbances

Social anxiety due to diarrhea

Embarrassment from defecating before reaching bathroom

2

What are the risk factors and precipitating factors for IBS?

žAffects 10-15% of the Western population bc of bad diet

žAffects 2-3 times more women than men

žMajor factors precipitating IBS:

—Stress

—Food intolerances

—Psychological factors

  • Depression
  • Anxiety
  • PTSD
3

How is IBS diagnosed?

žHistory from patient:

  • —Symptom history
  • —Past medical history
  • —Psychosocial history
  • —Family history
  • —Drug & dietary history- NSAIDS, digitalis, vasopressin, estrogen, & allopurinol

žDiagnostic testing to rule out other illness with similar symptoms: colorectal cancer, PUD, inflammatory bowel disease, & mal-absorption disorders

žRome III Criteria for diagnosis of IBS:

  • Abdominal discomfort or pain for at least 3 months, with onset at least 6 months before that has at least two of the following characteristics
  • Relieved with defecation
  • Onset associated with change in stool frequency and/or appearance
4

What is the treatment for IBS?

žEncourage pt to verbalize concerns

žDiet: At least 20-35 grams of fiber/day

žMay include psyllium (metamucil)

ž Avoid gas-producing foods (broccoli, cabbage, onion)

žSubstitute yogurt for milk products if lactose intolerant

žRelaxation & stress management

žAcupuncture & Chinese herbs

5

What are the medicines used for drug therapy of IBS? How do each sooth IBS symptoms? What is therapy that is effective for all pts with IBS?

žAnti-spasmotic agents (Bentyl): prevents diarrhea, may be helpful if taken before meals to alleviate pain

žLoperamide (Imodium): a synthetic opioid, enhances intestinal water absorption and sphincter tone

žLotronex: Used to treat diarrhea & severe pain in women who have failed other therapies. Monitored closely because of side effects (severe colitis)

No single therapy has been found effective for all patients.

6

What is appendicitis characterized by? When is it common?

Inflammation of appendix caused by kinking, edema, or blockage of the appendix. Blockage could be from popcorn kernals, nails, fecal matter, seeds, etc.

Generalized pain, localized to RLQ

Common in late adolescence and early adulthood; decreases after age 25; becoming more common in elderly d/t baby boomers (incr. pop).

7

What are the s/s of appendicitis?

Generalized pain localized to RLQ

Tenderness or pain at McBurney's point btwn the umbilicus and the iliac crest

Low grade fever

Guarding

Anorexia

N/V

Temporary constipation and failure to expel flatus

Rovsing's sign (pain on palpation of LLQ)

8

What are the complications of appendicitis?

Inflamed appendix fills with pus and may rupture causing peritonitis, can cause sepsis. If it ruptures, the pain dissipates.

Paralytic ileus (lack of bowel sounds) can occur (sometimes occurs after surgery)—A/B and wound drain, keep in Semi-Fowler’s.

9

How is appendicitis diagnosed?

High WBC (10-16) w/ shift to left or more than 75% neutrophils

CT scan

10

How is appendicitis treated?

Surgery: Lap or Traditional

Post-op:

  • Keep HOB up
  • Check Bowel Sounds (NPO until BS return)
  • Morphine for pain
  • C&DB (cough and deep breath)
11

What are the characteristics of inflammatory bowel disease? How is it classified?

žAutoimmune disease

žChronic, recurrent inflammation of the intestinal tract

Clinical manifestations are varied

žRemission with periods of exacerbations

No known cause. Possible include infectious agent, autoimmune reaction, food allergies, heredity (both classifications occur more families)

žIBD is classified based on symptoms:

— - Ulcerative colitis (UC)

— -Crohn’s disease (Can be caused by drinking too much carbonated soda) occurs most often in the ileum of the intestine

Both can be debilitating

12

What are the clinical differences btwn UC and Crohn's?

UC Crohn's

Age of onset: -teens-mid 30s -teens-mid 30s

Diarrhea: -common -common

Abd cramp: -common -common

Abd pain: -common -common

Fever: -acute attacks -common

W t loss: -rare - severe

Rectal bleed: -common -infrequent

Tenesmus: -common -rare

Malabsorption: -minimal -common

nutritional defic .

*Tenesmus is feeling that you constantly need to pass stools, even though your bowels are empty. May involve straining, pain, and cramping.

**UC can occur later in men (50s)

***Crohn's pts have more of a problem w/ weight loss bc of frequent diarrhea

13

What are the pathological differences between UC and Crohn's?

Location:

  • UC - continuous starts in rectum, spreads to colon. Most common in lg. intestine
  • Crohn's - skipped lesions occur anywhere in GI from mouth to anus, common in ileus of the sm. intestine.

Distribution:

  • UC - Continous areas of inflammation
  • Crohn's - Healthy tissue btwn inflammation

Depth:

  • UC - mucosa and submucosa thickness
  • Crohn's - Entire bowel wall

Granulomas (localized nodular inflammation):

  • UC - Occasional
  • Crohn's - Rare

Cobblestone mucosa:

  • UC - rare
  • Crohn's - very common

Pseudopolyps (projecting masses of scar tissue, develop from granulation tissue during repeated cycles of ulceration):

  • UC - common
  • Crohn's - rare

Small bowel involvement:

  • UC - minimal
  • Crohn's - common
14

What are the characteristics of ulcers in Crohn's?

Ulceration of the intestinal mucosa leads to thickened bowel and fissures can develop. Deeper ulcers than with U.C. More likely to have fistulas

15

What are the different complications associated with UC and Crohn's?

UC: Strictures (occasionally), perforation, toxic mega colon, carcinoma increased after 10 years, no recurrence after colectomy

Crohn's: Fistulas, Strictures, anal abscesses, perforation, carcinoma increased in sm. intestine, recurrence after surgery is common at anastomosis site.

16

How is IBD diagnosed? What diagnostic tests should a nurse anticipate ordered? What would be abnormal in those tests in a pt w/ IBD?

žRule out other diseases w/ similar symptoms, then determine if pt has UC or Crohn's

žCBC: typically shows iron deficiency in anemia from blood loss, WBC may be elevated w/ toxic mega colon or perforation

žElectrolytes: Decreases in Na, K, Cl, bicarb, and Mg levels d/t losses from diarrhea and vomiting

žAlbumin: With severe disease, poor nutrition, protein loss

žSed Rate: Elevated d/t chronic inflammation

žStool cultures for blood, pus, mucus

žSigmoidoscopy - Since UC begins in rectum, rectal biopsy may be adequate for dx. Not as thorough as colonoscopy

žColonoscopy - More likely for Crohn's as it is usually in sm. intestine, but can be anywhere

17

What assessment data should a nurse gather and anticipate for a client w/ IBD?

žSubjective data:

  • —Past medical history-infection, autoimmune disorders
  • —Family history
  • —Medications-use of antidiarrheal meds
  • —Functional health patterns-N/V/D, anorexia, weight loss, blood or mucus in stools, lower abdominal pain that is worse before defecation

žObjective data:

  • —Intermittent fever
  • —Emaciated appearance
  • —Fatigue
  • —Malaise
  • —Pale skin with poor turgor, dry mucous membranes, anorectal irritation, abd distention, hyperactive bowel sounds, abd cramps, tachycardia, hypotension
18

What are the goals of treatment for the IBD pt?

—Rest the bowel

—Control inflammation

—Combat infection

—Correct malnutrition

—Alleviate stress

—Provide symptomatic relief using drug therapy

19

What is the goal of drug therapy in the IBD pt? What classes of meds are used?

žThe goal of drug therapy is to induce and maintain remission to improve quality of life

ž5 classes of meds are used:

  1. —Aminosalicylates
  2. —Antibiotics
  3. —Corticosteroids
  4. —Immunosuppressants
  5. —Biologic and targeted therapy (started when initial therapies are not effective)
20

What are the characteristics of aminosalicylate therapy for IBD? How do they work? What should a nurse teach about them?

žSulfasalazine and Asacol (DMARD):

— First line tx for UC and Crohn’s

—Tx of mild to moderately severe attacks

— Anti-inflammatory specific to mucous membranes in intestines (doesn't work until it reaches the intestines)

—Maintenance of clinical remission

—After remission obtained, therapy is cont’d w/gradual reduction over several months

—Maintenance dose continued for at least 1 year

— May cause yellowish orange discoloration of skin and urine

— Teach patient to avoid sunlight due to photosensitivity

Do not take other salicylates (Aspirin)

21

What are the drugs and parameters for antimicrobial use for IBD?

žUsed even though no infectious agent has been identified

—Metronidazole (Flagyl)

—Ciprofloxacin (Cipro)

22

What corticosteroids are used in tx of IBD? Why? What teaching should a nurse implement?

ž—P rednisolone and budesonide ( Entocort )

Corticosteroids are used to achieve remission but not effective in maintaining it

— Decrease inflammation

Oral for mild to moderate dz,

IV steroids for severe dz

—Rectal foams & cortisone directly applied

—Given shortest possible time d/t side effects associated with long term use

23

What immunouppresants are used to treat IBD? What are their characteristics?

žImuran and Purinethol: Given to maintain remission after corticosteroid tx

žMethotrexate (more for Crohn’s): watch for flu like symptoms, bone marrow depression, and liver dysfunction (need to check CBC, liver enzymes). —Causes birth defects

žAnti-tumor Necrosis Factors (Remicade, Humira) (Crohn’s)

24

Why are sedatives used for IBD?

Reduce anxiety and restlessness

25

What anti-diarrhea agents are used in IBD?

Imodium and Lomotil

26

What percent of those with UC and Crohn's require surgery? When is surgical therapy indicated?

UC: 25-40%, cured with colectomy

Crohn's: 75%, but can return in sm. intestine

žIndicated if:

  • —Pt fails to respond to tx
  • —Exacerbations are frequent & debilitating
  • —Massive bleeding, perforation, strictures, or obstructions
  • —Carcinoma develops
27

What surgical procedures are used for IBD?

žTotal proctocolectomy with permanent ileostomy

  • removal of the colon, rectum, and anus with closure of the anus
  • the end of the ileum is brought out to form a stoma in the RLQ

žTotal proctocolectomy with continent ileostomy

  • formation of a Kock pouch which is drained by a catheter

žTotal colectomy with ileo-anal reservoir

  • Combo of 2 sx, 8-12 weeks apart
  • 1 sx- colectomy, ileoanal anastomosis, reservoir construction, and temporary ileostomy
  • 2 sx- closing ileostomy to direct stool to new reservoir
28

What post-op care is indicated for IBD surgeries?

Pain assessment. Frequently comes from gas and abd distention

Monitor bleeding

Control n/v

žIf ileostomy is formed, monitor:

  • —Stoma viability
  • —Mucocutaneous juncture
  • —Peristomal skin integrity
  • —Ileostomy output (initially 1500-2000ml/24 hours)

žObserve for signs of hemorrhage, abdominal abscess, small bowel obstruction, and dehydration

29

What are the goals and principles of nutrition therapy for the IBD pt?

—Adequate nutrition without exacerbating symptoms

—Correct & prevent malnutrition

—Replace fluid & electrolyte losses

—Prevent weight loss

žBalanced, healthy diet with sufficient calories, protein, and nutrients; individualized

žInitially NPO (bowel rest)

ž High-calorie, high-protein, low-residue diet

ž Avoid foods that cause/exacerbate symptoms:

  • — Cold foods
  • — High fat foods
  • — Dairy products (lactose intolerant)
  • — High -residue foods (whole-wheat bread, cereal w /bran, nuts, raw fruit )
  • — Smoking increases GI motility ( avoid)

žEnteral supplements & parenteral nutrition may be needed

žSupplemental iron may be necessary

žMay need vitamin therapy (B-12 injections)

30

What nursing interventions should a nurse implement for the IBD pt?

—Assess pt, check labs, etc

—Accurate I & O

—Nutritional teaching

—Medication teaching

—Rest

—Psychotherapy

—Post-op care/teaching

31

What are the characteristics of polyps in the large intestine?

žArise from mucosal surface of colon & project into the lumen

žCommon in rectosigmoid area

žMost are asymptomatic

žOccasional rectal bleeding

Places the pt at high risk for developing cancer

32

What are the characteristics of Familiar Adenomatous Polyposis (FAP)?

žGenetic disorder characterized by hundreds to thousands of polyps that eventually become cancerous, usually by age 40

žAutosomal dominant

—50% of offspring will carry the gene

—Anyone with family hx should have genetic testing in childhood

—If the gene is present, colorectal screening begins at puberty and colonoscopy at age 16

žTx is prophylactic removal of colon, by age 25

žThese people are also at risk for other cancers, so they should have lifetime cancer surveillance

33

What diagnostic studies are used for pts w/ polyps?

žBarium enema

žColonoscopy: regular or pill

žSigmoidocopy

žCT/MRI

žAll polyps are considered abnormal & should be removed

žSurgery not indicated unless carcinoma or certain cases of polyposis are present

34

What are the nursing management principles for scopes?

žObservation after procedure:

-—Slight abdominal pain, cramping and gas is normal after procedure

-—Watch for symptoms that indicate hemorrhage or perforation:

  • Bleeding
  • Fever
  • Severe abdominal pain
  • Abdominal distention
35

What are the characteristics of colorectal cancer (CRC)?

žSecond leading cause of cancer-related deaths in U.S.

žInsidious onset

žSymptoms do not appear until disease is advanced

žVital: Regular screening to detect precancerous lesions

ž 85% of cases arise from adenomatous polyps

36

What are the risk factors of CRC?

žMore common in men than women

Most occur in the latter end of the colon

žMortality rates higher among AA

žRisk factors:

  • —Increasing age
  • —Family or personal hx or CRC
  • —Colorectal polyps
  • —IBD
  • —Obesity
  • —Smoking
  • —Large intake of processed or red meat
37

What are the clinical manifestations of CRC?

žNonspecific and do not appear until advanced

  • —Asymptomatic
  • —Alternating constipation and diarrhea
  • —Change in stool caliber (narrow, ribbon-like)
  • —Sensation of incomplete evacuation
  • —Obstruction
  • —Vague abdominal discomfort or cramping
  • —Colicky abdominal pain
  • —Anemia
  • —Occult bleeding
  • —Weakness
  • —Fatigue
38

What are the guidelines of screening for CRC?

žBegin at age 50 to 75 years old

žFOBT (fecal occult blood test)

  • —3 consecutive stool samples
  • —Yearly

žSigmoidoscopy (misses 50%)

  • —Every 5 years

ž Colonoscopy (gold standard for dx)

  • — Average risk-should be done every 10 years
  • — AA should & high risk should start at 45
39

What is the only treatment for CRC? What are the goals of this treatment?

žSurgery is the only cure

žSurgery goals:

  • —Complete resection of the tumor
  • —Exploration of abdomen to determine metastasis
  • —Removal of lymph nodes that drain the area where CA is located
  • —Restore bowel function
  • —Prevent surgical complications: peritonitis and perforation

žReduction of colonic bacteria is done prior to sx (GoLYTELY)

žThe site of CRC determines the site of the resection

40

What are the principles of chemo and radiation therapy for CRC?

žUsed an adjunct therapy following colon resection

žUsed for palliative care for non-resectable CRC to reduce tumor size

žCan be used prior to surgery to reduce tumor for easier removal

žChemo recommended when patient has + lymph nodes

žFYI: Current chemo protocol (Triple protocol)

  • —Folfox (5-FU plus leucovorin and oxaliplatin)
  • —Folfiri (5-FU plus leucovorin and irinotecan)

Some people cannot handle the triple therapy. Capecitabine is used as an acceptable tx.

Don't need to know specific drugs.

41

What is an ostomy? A stoma?

An ostomy is a surgical procedure that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen.

A stoma is an opening on the surface of the abdomen, created when the intestine is brought through the abdominal wall & sutured to the skin. Fecal matter empties via stoma rather rectum. May be permanent or temporary

42

What does a nurse need to know about post-op care of a stoma? What do the different colors mean?

Assess color, size, suture line.

žEdema

  • Mild to moderate: Normal in initial post-op period & first 2-3 weeks. Can be due to trauma
  • —Moderate to severe: Obstruction, allergic reaction to food, gastroenteritis

žBleeding: small amount normal after surgery or when touched, otherwise should be evaluated

Report any separation, report nausea and abd distention STAT.

During first 24-48 hours, mucosal drainage then passage of flatus is normal.

Post op: Ambualte to get the gut moving!

—Normal: shiny and moist, dark pink to red. Should look like the inside of your mouth.

Light pink (pale) - anemia

Dark red-blue (dusty) color - decreased circulation (ischemia)

Blue-gray to black color - strangulated bowel, surgical emergency

43

Why are ostomies used?

žUsed when normal elimination is no longer possible

žFor example:

  • —Person has CRC, the diseased portioned must be removed along with a certain margin of healthy tissue
  • —Sometimes the tumor and tissue can be removed leaving enough healthy tissue to anastomose (reconnect) the remaining ends of the healthy bowel.
  • —Other times there is too much taken to reconnect therefore the need for an ostomy

žOstomies are described according to their location and type

44

What are the different types of ostomies? How does the location of the ostomy affect output from the stoma?

žIleostomy: Ostomy in the ileum. Output from ileostomy has not entered colon, therefore, it is liquid to toothpaste consistency, drains continually and a pouch must be worn. More at risk for dehydration.

žColostomy (sigmoid or transverse): Ostomy in the colon. May be temporary or permanent. Sigmoid ostomy output resembles normal formed stool and patients can regulate these and not have to wear a bag at all.

Cecostomy: Ostomy in the cecum, usually temporary

The more distal the ostomy is the more the intestinal content resemble feces eliminated by intact colon and rectum.

45

What are the characteristics of a single barrel or end stoma?

žEnd stoma (single barrel):

  • —Surgically created: proximal end of bowel used to create a single stoma
  • Distal portion removed (permanent) or sewn together and left in the abdominal cavity (Hartmann’s pouch - procedure done to close the end of the sigmoid-rectal area w/ a colostomy formation, permanent).
  • —Leaving the distal pouch in leaves the potential for the bowel to be anastomosed again
  • Bowel is brought through abd wall, foled onto itself like a turtleneck collar and sutured to skin
  • Proximal end of bowel ends in stoma, distal portion of bowel sutured and inactive.
  • No connection btwn proximal and distal portion of bowel.
46

What are the characteristics of a loop stoma?

—Loop of bowel brought to the surface & anterior wall opened to provide fecal diversion

A plastic rod is used to hold it in place for 7-10 days

Usually temporary

Surgeon brings out an intact bowel loop through the abdominal wall and then makes an incision on the top of the loop.

All of these require use of ostomy appliances to collect fecal matter.

47

What are the characteristics of a double-barrel stoma?

—Bowel is divided & both ends brought through abdominal wall as separate stomas

Proximal – functioning stoma, output is stool

Distal – mucous fistula, output is mucus

Usually temporary diversion

48

What are the stool characteristics of the colostomy compared to the ileostomy?

—Colostomy:

  • ascending – semi-liquid
  • transverse – semiliquid to semiformed
  • sigmoid – formed

—Ileostomy: liquid to semiliquid

49

What two preventative treatments are musts when caring for ostomies? Which type of ostomy does not need these and can have irrigation and bowel training?

A stool pouch and skin barriers are a must w/ ileostomy and most colostomies.

Generally, only w/ sigmoid colostomies bowel training and irrigation can be performed, pouch and barriers may not be needed.

50

What are the principles of pre-op care and post-op care of the ostomy patient?

Preoperative care

  • Psychologic preparation-change in body image
  • Colostomy teaching
  • Bowel preparation- Mag Citrate & GoLytely
  • IV & oral antibiotics to decrease intracolonic bacteria

Post-op care

  • Assessment of the stoma
  • Protecting the skin
  • Selecting pouch
  • Helping patient adapt – physically & psychologically
51

What are a nurse's responsibilities regarding maintenance and patient teaching in colostomy care?

žExplain what colostomy is for and how it functions

žDescribe underlying need that resulted in need for ostomy

žHave patient demonstrate and practice the following activities

—Remove old skin barrier, cleanse skin and apply new skin barrier

—Apply, empty, clean and remove the pouch

—Empty the pouch before it is 1/3 full to prevent leakage

—Irrigate the colostomy to regulate bowel elimination (optional)

žExplain how to obtain colostomy supplies

žTalk about potential strain on sexual activity

Irrigation stimulates emptying of the colon. When the colon is irrigated and emptied on a regular basis, no stool is eliminated between irrigation sessions. This allows the patient to wear only a pad or small pouch over the stoma.

If the stoma bag gets too full and leaks, it will never be sealed again. You must clean it up and change the bag. Gastric contents will cause skin breakdown.

52

What should a nurse know about nutritional therapy in ostomy management? What foods should ostomy patient avoid? What foods could cause diarrhea and obstruction of the ostomy?

Promote fluid intake of at least 3000 ml/day

  • Increase during hot weather, excessive perspiration, and diarrhea

Teach s/s of electrolyte imbalances

Call HCP if fever, diarrhea, skin irritation, stoma problems

Dietary modification: well-balanced diet

Avoid:

  • odor-producing foods - eggs, garlic, onions, fish, asparagus, cabbage, broccoli, alcohol
  • gas forming foods - broccoli, beans, carbonated beverages, beans, cabbage, cauliflower, brussel sprouts, asparagus

Stoma output varies: modify diet based as needed

  • Diarrhea: Cabbage, beer, spinach, green beans, coffee, raw fruits, spicy foods
  • Obstruction: Nuts, raisins, popcorn, dried fruits, seeds, raw veg, celery, corn, meats with casings. Chew these VERY thoroughly
53

What does a nurse need to know and teach about ileostomy care?

Drainage is frequent; may be damaging to the skin

Pouch worn at all times & emptied when 1/3 full

If leakage occurs, the pouch must be removed, changed, and the skin cleaned & dried promptly

Low - fiber diet ordered initially & fiber re-introduced gradually

Avoid popcorn, coconut, mushrooms, olives, stringy vegetables, food with skins, dried fruits and meats with casings (obstruction)

Susceptible to obstruction because the lumen is less than an inch in diameter

54

What should a nurse anticipate regarding normal and harmful behaviors during a patient's adaptation and acceptance of an ostomy?

Gradual process

Grief period is common

Concerns : Body image, sexuality, change in lifestyle

Psychological support-experience fear and anxiety

May become angry, depressed or resentful

Might not want to look at the ostomy. Have them look at it w/ a mirror if they don't want to directly see it.

Pt. must not be forced too quickly into care of stoma until ready

ADL’s are generally resumed in 6-8 weeks

Resuming sports varies from HCP to HCP

Refer patients for counseling if needed

55

What are some complications of an ostomy?

Prolapse - The bowel protrudes out of the stoma

Retraction of stoma in bowel - surgical emergency

Necrosis of the stoma - surgical emergency

Peristomal hernia - protrusion of abdominal contents through the abdominal wall defect created during ostomy formation, most common complication

Peristomal skin breakdown or infection - usually from stool at the site or fungal infection.

  • Will have red rash, pustules, pruritis at the site, possibly candida if fungal.
  • Use nystatin powder to treat topical candidiasis
56

What are some other principles of ostomy care a nurse should know?

Change if ANY leakage: DON’T be a LAZY nurse--it will be detrimental to the patient’s skin

Ileostomies: More liquid and acidic drainage erodes wafer. Average 3-7days for wafer changes

Keep pouch emptied to prevent pulling away from the skin which leads to spilling of contents which leads to breakdown and infection

57

How would a nurse change the stoma bag?

1. Measure the opening size for stoma

2. Apply ostomy powder and skin prep. This takes off the oil in order for ostomy to stick

3. Apply paste to ostomy wafer

4. Place ostomy wafer, can apply water-resistant tape around wafer if needed

5. Paste to ostomy wafer before applying bag, don't get paste on the stoma

6. Place the bag, it snaps onto the ring

58

What is a two piece ostomy pouch? What teaching should a nurse include for the patient?

There is a separate wafer and pouch.

It allows the pouch to be removed, rinsed out, and new pouch to be put on daily.

Teaching:

  • End of pouch should be rolled over the clamp only ONE time.
  • žKeep supplies away from the sun or extreme temperatures
  • Precut supplies before flying
  • Pre-sized wafers available once stoma size determined
59

What teaching about meds should a nurse give to an ileostomy pt?

Liquid and tablet meds only, preferably liquid.

Extended release tablets will not be absorbed properly. (Most colostomy pts do not have this problem)

60

What should a nurse know before irrigating a stoma?

Never force into opening. If unable to insert tube into stoma, call MD as stoma stenosis (narrowing) may be developing.

Stop for a while if cramping occurs, then resume more slowly

61

What complications should a pt w/ an ostomy report?

žChange in configuration, color, consistency of stool

žBleeding through stoma or rectum

žPersistent leakage around wafer, diarrhea, or lack of stool

žChange in contour or color of stoma (should be brick red like inside of mouth)

62

What are diverticula? What is the difference between diverticulitis and diverticulosis?

žDiverticula: saccular dilations or outpouchings of mucosa through circular smooth muscle of the intestinal wall. —Pockets in the intestinal tract. things get in them. Frequently found in the sigmoid colon.

žDiverticul osis –multiple, non-inflamed.Often free of symptoms or slight abdominal discomfort

žDiverticul itisinflammation of diverticula

63

What is the etiology of diverticulitis?

žCommon GI disorder

žAffects 5% of population by age 40

— 50% of the population by age 80

Affects men & women equally, but men tend to have more complications

Most are asymptomatic

žNo known cause

žAppears to be associated with a deficiency in dietary fiber

64

What is the patho of diverticulosis? Diverticulitis?

Diverticulosis:

  • When diverticula form, smooth muscle of the colon wall becomes thickened
  • Lack of dietary fiber slows transit time & more water is absorbed from the stool, making it difficult to pass through the lumen
  • Decreased bulk of stool & more narrowed lumen in the sigmoid colon cause high intraluminal pressures
  • These factors are believed to contribute to the formation of diverticula

Diverticulitis:

  • žCause of diverticulitis is r/t retention of stool in the diverticulum, forming a hardened mass called a fecalith
  • žInflammation & usually small perforations form
  • žInflammation spreads to the surrounding area in the intestines, causing tissue edema
  • žAbscesses may form, or complete perforation with peritonitis may occur
65

What are the clinical manifestations and complications of diverticulitis?

žMajority of pts have no symptoms

žCrampy abdominal pain

žBloating

žFlatulence

žAlternating constipation & diarrhea

žApproximately 15% of pts. with diverticulosis progress to acute diverticulitis

žAbdominal pain over area involved

žTender LLQ mass w/palpation

žFever, increased WBC, chills, nausea, anorexia may be present

žElderly patients may have normal WBC, be afebrile & have little, if any pain

žComplications include perforation, peritonitis, abscess & fistula formation, bowel obstruction, & bleeding

žBleeding manifested by maroon stools & usually resolves spontaneously

66

What diagnostic tests are utilized in diverticulitis?

žBased on history and physical

žAbdominal and chest x-rays rule out other causes of abdominal pain

žCT scan with oral contrast is preferred diagnostic tool

žSome other test that will be done could include:

  • —CBC
  • —Urinalysis
  • —Barium enema
  • —Fecal sample
  • —Colonoscopy
  • —Barium enema & colonoscopy not done if pt. has acute diverticulitis due to risk of perforation/peritonitis
67

How should a nurse teach a patient to prevent diverticular disease?

High-fiber diet, mainly fruits and veggies

—Decreased intake of fat and red meat

—High levels of physical activity decrease risk

—Weight loss if obese

—Bulk laxatives (Metamucil)

—Increased fluid intake

68

What is the treatment and goal of treatment for acute diverticulitis?

Some patients can be managed at home with PO antibiotics, while others have to be hospitalized if pain is severe

žBowel rest

žAntibiotic therapy

žNPO

žNGT

žIV fluids

žWatch WBC

žPain management (Morphine)

žApprox 30% acute diverticulitis will require surgical intervention (resection and/or temp colostomy)

žThe goal of treatment is to let the colon rest and the inflammation subside

ž

69

What are the principles of surgical intervention for diverticulitis?

žReserved for patients with complications, such as abscesses or obstructions

žInvolves resection an obstructing inflammatory mass

žMay require resection of the involved colon with a temporary diverting colostomy

žThe colostomy is re-anastamosed after the colon has healed

70

What should a nurse include in in interventions for a pt w/ acute diverticulitis?

žDietary modification

žActivity

žIncreased fluid intake

žWeight reduction

žMedication teaching

žS/S of perforation/peritonitis (severe abdominal pain)

žHow to decrease complications & avoid exacerbation

71

What are the characteristics of hemorrhoids?

žDilated veins

žInternal or External

žCommon in all age groups

žAppear periodically

žSupporting tissue in the anal canal weakens, usually from straining & venules become dilated

žIn addition, blood flow is impaired through the veins of the hemorrhoidal plexus

žAn intravascular clot in the venule results in a thrombosed external hemorrhoid

Most common cause of bleeding w/defecation

Over time may cause iron-deficiency anemia

žS/S

  • —rectal bleeding
  • —pruritis
  • —prolapse
  • —pain
72

What are some causes for hemorrhoids?

—Pregnancy

—Prolonged constipation

—Diarrhea

—Straining to defecate

—Heavy lifting

—Prolonged standing & sitting

—Portal hypertension

73

What methods are used for diagnosis of hemorrhoids? How is it treated?

Diagnostics:—

  • Digital Rectal Exam, anoscopy, or sigmoidoscopy
  • —Visual inspection

—Therapy directed toward cause & symptoms:

  • —High-fiber diet
  • —Increase fluid intake
  • —Ointments w/anti-inflammatory agents & analgesics for topical use: —dibucaine (Nupercainal), Hydrocortisone, Witch hazel
  • —Stool softeners
  • —Sitz baths
  • —Ice/warm packs for thrombosed external hemorrhoids
  • —Internal hemorrhoids may require surgical intervention
74

What are the treatments for external and internal hemorroids? When is surgery indicated?

žExternal hem. conservative treatment

žInternal hem. nonsurgical approach

  • —Band ligation – through anoscope, ligated with rubber band
  • —Infrared coagulation – using infrared or electrical currents
  • —Cryotherapy – rapid freezing of hemorrhoid
  • —Laser treatment – used less often

žHemorrhoidectomy

  • —used in prolapse or marked protrusion
  • —severe pain
  • —severe bleeding
  • —large hemorrhoids
  • —multiple thrombosed
75

What are important concepts for a nurse to know in post-op hemorrhoid management?

žConstipation prevention

žDiet teaching

žOTC med use

žSitz baths (15-20 min 2-3 Xs a day X 1 week)

  • —Started 1-2 days after sx
  • —Provides comfort
  • —Keeps anal area clean

žPacking may be inserted in rectum, removed day 1 or 2

žSphincter spasm pain managed by opiods

žStool softeners

  • —painful to defecate
  • —Some people avoid going to bathroom due to dreaded pain
  • —docusate (Colace)
  • —If no BM in 2-3 days, oil-retention enema is given

žTeach s/s of complications & when to call doctor: excessive pain, bleeding or fever

Be sensitive in talking to the pt about hemorrhoids or surgical site, some are embarrassed about it.

ž

76

What is an anal fissure? What are the causes? How are they classified?

Skin ulcer or crack in the lining of the anal wall

žCaused by:

  • —Trauma
  • —Local infection
  • —Inflammation

Classified primary or secondary:

—Primary – from local trauma associated with defecation

  • High pressure in the internal anal sphincter can result in ischemia & result in fissuring
  • Vaginal delivery

—Secondary – due to a variety of conditions

  • Inflammatory bowel disease (Crohn’s, UC)
  • Prior anal surgery
  • Infection: Syphillis, TB, Gonorrhea, Chlamydia, Herpes, or HIV
77

What are the clinical manifestations of an anal fissure? How is it diagnosed?

žAnal pain

  • —Severe during and after defecation
  • —Described as “passing broken glass”

žBleeding

  • —Bright red
  • —Slight

žConstipation may result from a fear of pain with defecation

žDiagnosed through physical examination

78

What are the treatments for anal fissures?

žFiber supplements

žAdequate fluid intake

žSitz baths

žTopical analgesics

  • —Nitrates
  • —CCB
  • —Anesthetic suppositories (Anusol-HC)

žBowel regulation – mineral oil/stool softeners

žBotox injections

žMost acute fissures take 2-4 weeks to heal

79

What is an anal fistula? What are the usual problems that accompany the disease?

žAbnormal tunnel leading out from the anus or rectum

žMay extend to the outside of the skin, vagina, or buttocks

žComplication of Crohn’s disease & may progress to anal abscess

žFeces may enter the fistula & cause infection

žMay have persistent blood-stained purulent discharge or stool leakage from the fistula. Patient may need to wear a pad to prevent staining of clothes

80

What is the treatment for an anal fistula? How will you care for it post-treatment?

žFistulotomy

  • —the fistula is opened
  • —healthy tissue is allowed to granulate

žFistulectomy

  • —excision of the entire fistulous tract
  • —Gauze packing is inserted and the wound is allowed to heal through granulation

žCare is the same as with a hemorrhoidectomy

81

What are the pathophysiology and complications of an intestinal obstruction?

ž6-8 L of fluid enter the small bowel daily

žMost of the fluid is absorbed before it enters the colon

ž When there is an obstruction, fluid, gas and intestinal contents accumulate above the obstruction

žDistal bowel collapses

žB owel above the obstruction becomes distended as the intraluminal pressure rises

žThe increased pressure causes fluid and electrolytes to be leaked out of the blood vessels to the peritoneal cavity, which leads to severe reduction in circulating blood volume causing hypotension and hypovolemic shock.

žIf the blood flow in the intestines in inadequate, bowel tissue becomes ischemic, then necrotic and the bowel may perforate.

žIn some cases the bowel can become so distended that the blood flow is halted causing edema, cyanosis and gangrene of bowel--Called intestinal strangulation or intestinal infarction. Must be corrected quickly or will lead to rupture, massive infection, and death.

82

What causes intestinal obstruction? What are the different classifications and types of intestinal obstruction?

Occurs when intestinal contents cannot pass through the GI tract.

Occurs anywhere in the colon

Partial or complete

Types:

  • Mechanical
  • Non-mechanical
  • Pseudo-obstruction
  • Vascular
83

What are the most common causes of mechanical obstruction in the small intestine and in the large intestine?

Mechanical:

Small intestine

  • Surgical adhesions most common cause
  • Hernias and tumors next leading cause

Large intestine

  • Carcinoma most common cause
  • Followed by volvulus (an obstruction with a loop of bowel that has twisted on itself) and diverticular disease
84

What characterizes a non-mechanical obstruction?

—Occurs from a neuromuscular or vascular problem

—Paralytic ileus most common form (lack of intestinal peristalsis and no bowel sounds)

—Can occur after surgery

—Peritonitis

—Inflammatory response (acute pancreatitis, appendicitis)

—Hypokalemia

—Thoracic or lumbar fractures

85

What are pseudo-obstructions and vascular obstructions?

Pseudo:

  • —Apparent obstruction without demonstration by x-ray
  • —Is idiopathic (no obvious reason or cause)

Vascular:

  • —Rare
  • —Result of interference of blood supply to a portion of the intestines
86

What are the clinical manifestations of an intestinal obstruction?

žDepends on location

žN/V, poorly localized abd. pain, abd. distention, inability to pass flatus, obstipation (obstruction of flow of feces) and s/s of hypovolemia: cold hands and feet, light headedness, infrequent urination, increased heart rate, weakness.

žNO bowel sounds below obstruction.

žHigh pitched bowel sounds above obstruction. (Borborygmi – audible bowel sounds)

žNausea/Vomiting

  • —Distal obstruction can cause vomitus containing feces.
  • —Projectile containing bile-salts.
  • —Metabolic alkalosis with high obstruction N & V

žAbdominal pain

  • —Vomiting relieves pain in upper obstructions
  • —Is more constant with lower obstructions (and will most likely experience abdominal distension).
  • Wave like pain – classic in mechanical obstruction
  • Paralytic ileus – more constant & generalized.
  • Strangulation – severe constant pain.
87

What are the clinical s/s of intestinal obstruction in the small intestine compared to the large intestine?

Small: Rapid onset, frequent and copious vomiting, colicky,cramp-like, intermittent pain, feces for a while, increased abd distention.

Large: Gradual onset, vomiting is rare, low-grade cramping abd. pain, no bowel movement, increased abd distention.

88

What are the diagnostic studies used for intestinal obstruction?

žH&P

—CT scans and abdominal x-rays are most useful

žSigmoidoscopy and colonoscopy provide direct visualization

žElevated WBC indicates strangulation or perforation

žDecreased H & H indicate bleeding

žElectrolytes, BUN & creatinine are monitored for dehydration

89

What are the principles of care a nurse should anticipate regarding intestinal obstruction?

žSTAT surgery if bowel strangulated

žMost resolve with conservative tx

žInitial medical tx include:

  • —NPO
  • —NG tube
  • —IV fluid replacement with NS or LR ( since the fluid lost from the gut is isotonic)
  • —Add K+ to IV fluids after renal function confirmed
  • —Analgesics for pain control

žSurgery if obstruction does not improve within 24 hrs

žParenteral nutrition may be needed to correct nutritional deficits

žSurgery resecting of obstruction & anastomosing the remaining healthy bowel

žPartial or total colectomy, colostomy, or ileostomy may be required

90

What are the principles of nursing management with intestinal obstruction?

žDetermine location, duration, intensity, and frequency of abdominal pain, and whether abdominal tenderness or rigidity is present

žRecord the onset, frequency, color, odor, & amount of vomitus

žInspect the abdomen for scars, visible masses & distention

žAuscultate for BS, document character & location

žAssess bowel function, including passage of flatus

žMeasure abdominal girth, and palpate for muscle guarding and tenderness which are signs of peritoneal irritation and are indicative of strangulation

žMaintain a strict I & O

žFoley (report output less than 0.5ml/kg of body weight per hour because it signals inadequate vascular volume and the potential for acute renal failure)

žRising BUN and creatinine indicates sign of renal failure

žIf HCP decides to wait and see if obstruction resolves on its own, assess the abdomen regularly and monitor for severe abdominal pain, leukocytosis, fever and tachycardia

91

What defines acute and chronic diarrhea?

Diarrhea is passage of at least 3 loose or liquid stools per day.

Chronic is if it lasts greater than 4 weeks

Not a disease, but a symptom.

Means different things to different patients

92

What are the possible pathologies?

žDecreased fluid absorption

žIncreased fluid secretion

žMotility disturbances

93

What are different causes of diarrhea?

žViral

  • —Rotavirus

žBacterial

  • —E coli (uncooked beef or chicken, fruits and vegetables grown in manure fertilized soil)
  • —Shigella
  • —Salmonella (undercooked eggs or chicken)
  • —Staphylococcus
  • —Clostridium difficile, often from antibiotics destroying normal intestinal flora, CONTACT ISOLATION!, must wash hands w/ soap and water, must place in a private room
  • —Campylobacter

žParasitic

  • —Giardia lamblia (drinking water from contaminated lakes or pools)
94

What are the clinical manifestations of diarrhea?

žMay be acute or chronic

žAcute diarrhea most commonly results from infection

žSystemic manifestations:

  • —Fever
  • —Nausea
  • —Headache
  • —Vomiting
  • —Malaise
  • —Poor skin turgor

žAcute diarrhea in the adult is usually self-limiting & continues until the irritant or cause is excreted

žPeople can remain contagious for 2 weeks after viral diarrhea

95

What are the complications of prolonged diarrhea?

žChronic when

  • —It persists for more than 2 weeks
  • —When it subsides & returns more than 2-4 weeks after initial episode

žSevere diarrhea may be debilitating & life-threatening

  • —Dehydration
  • —Electrolyte disturbances (hypokalemia)
  • —Malabsorption
  • —Malnutrition

žOne of the major causes of death throughout the world

Very hard on the elderly or immune-suppressed, can kill them

96

What are the main diagnostics a nurse should anticipate for diarrhea?

žThorough pt history and physical exam

  • —Describe the character of the stools and any associated symptoms.
  • —Any travel, medication use (OTC), diet, previous surgery, interpersonal contacts, family history

žLab tests:

  • —Blood count to identify infection, anemia, iron, & folate deficiencies
  • —Elevated liver enzyme levels
  • —Electrolyte disturbances
  • —BUN/CREAT deficiencies

žStool samples

  • —Blood, mucous, WBC’s, parasites
  • —Stool cultures
  • —Stool electrolytes, pH, & osmolality
  • —Stool fat & undigested muscle fibers

žEndoscopy to examine mucosa

žUpper & lower radiologic studies with barium contrast

97

What treatment measures should a nurse anticipate for a patient w/ diarrhea?

žBased on the cause

žFoods and meds that cause diarrhea should be avoided

žAimed at replacing fluid & electrolytes & decreasing number, volume, & frequency of stools

žOral solutions (Gatorade, Pedialyte, etc) for mild diarrhea

žSevere diarrhea may require parenteral nutrition (fluids, electrolytes, vitamins)

98

What medicines should a nurse anticipate administering to a patient w/ diarrhea?

žAntidiarrheals

  • —Once the cause has been determined
  • —Contraindicated in infectious diarrhea b/c they prolong exposure to the infectious organism
  • —Inhibit GI motility, decrease intestinal secretions and decrease CNS stimulation of the GI tract
  • Pepto bismol
  • Imodium
  • Lomotil

žAntispasmotics to help with abdominal cramping

žProbiotics

žAntibiotics for treating specific organisms

  • —Clostridium Difficile (should place the client in a private room with contact isolation)
  • Vancomycin or Flagyl
99

What interventions should a nurse implement w/ the patient w/diarrhea?

žAll cases of diarrhea should be considered infectious until cause is known

žStrict infection control precautions

žGood hand washing before and after contact with pt

žFlush vomitus and stool in toilet

žWash contaminated clothes immediately with soap and hot water

žDiscuss proper food handling, cooking and storage

žC Difficile hard to kill. Alcohol based and ammonia based hand cleaners are ineffective —use soap and water!

  • —Must use 10% bleach solution to clean room
  • —Have to be put in isolation
  • —Disposable equipment, even stethoscope
  • —Visitors and hosp staff must be gowned and masked

ž

100

What characterizes constipation?

žA decrease in frequency of bowel movements from what is “normal”

žFrequency varies from 3 per day to 1 every 3 days

žAlso includes difficulty passing stools, decrease in stool volume and retention of feces in the rectum

žDaily bowel movement is not necessary

101

What are some common causes of constipation?

—Insufficient dietary fiber

—Inadequate fluid intake

—Decreased physical activity

—Ignoring the urge to defecate - causes the muscles in the rectum to become insensitive to the presence of feces. The prolonged retention of feces results in drying of the stool due to water absorption. The harder and drier the feces, the more difficult it is to expel

—Medications like opioids

—DM, Parkinson’s & MS slow GI transit time

—Depression and stress

Some people believe that if they do not have a BM every day then they are constipated, which leads to chronic laxative use and cathartic colon syndrome (the colon becomes dilated and atonic). Ultimately the person loses the ability to defecate without the use of a laxative

102

What are the clinical manifestations of constipation?

žVaries from chronic discomfort to acute abdominal pain

žStools are absent or hard, dry and difficult to pass

žAbdominal distention

žBloating

ž Increased flatulence

žIncreased rectal pressure

103

What are some complications of constipation?

žHemorrhoids

žFecal impactions

žPerforation

  • —Abdominal pain
  • —N & V
  • —Fever

—Elevated WBC

žRectal mucosal ulcers and fissures

žDiverticulosis

Valsalva maneuvers (straining to defecate) may be fatal for patients with heart failure. During straining the patient inhales deeply and holds breath while contracting abdominal muscles and bearing down. This increases both intraabdominal and intrathoracic pressures and reduces venous return to the heart. The heart rate drops causing the cardiac output to decrease and arterial pressure to decrease. When the patient relaxes, the thoracic pressure falls, resulting in a sudden flow of blood into the heart, tachycardia and an immediate rise in arterial pressure. This sudden change can be fatal to individuals who can not compensate for the sudden return of blood to the heart.

104

What diagnostic procedures are used with constipation?

žThorough history and PE: Ask the patient about usual defecation patterns and habits, diet, exercise, use of laxatives

žAbdominal xrays

žBarium enema

žColonoscopy

žSigmoidoscopy

žAnorectal manometry

105

What are some treatment options for constipation?

žIncreasing dietary fiber àEat 20-30 g fiber/day

  • —Fruits
  • —Vegetables
  • —Grains

žIncreasing fluid intake (2000mL daily) Avoid caffeine- it stimulates fluid loss thru urination

žExercise- walk, swim or bike 3 Xs a week. Also do abdominal exercises to strengthen core

žLaxatives- do not overuse

žEnemas-do not overuse

žStool softeners are used to prevent

žDo not delay defecation

žEstablish a regular time to defecate

106

What are two nursing interventions for hernia patients?

Wear truss and NO coughing post-op