Adult Care GI CH 56 & 57

Weakness in abdominal muscle wall - part of bowel or other structure protrudes

Herniation *Factors that contribute: -congenital or acquired muscle weakness, -increased intraabdominal pressure (pregnancy, obesity, lifting heavy objects)

What are the most common signs of colorectal cancer?

Most common signs are rectal bleeding, anemia & change in stool consistency &/or shape

N/V BEFORE pain may be

gastroenteritis

True or False: Emotional stress is a risk factor for development of irritable bowel syndrome (IBS). True False

(False) Rationale: Emotional stress does not cause IBS, but people with IBS may have their bowels react more to stress. So, if a patient already has IBS, stress can make the symptoms worse. Learning to reduce stress can help with IBS. With less stress, patients may have less cramping, pain, and better symptom relief.

Manifestations of non-mechanical obstruction

- pain is constant, diffuse, distention usually normal, decreased or absent sounds, vomiting (gastric contents/bile)...these are post surgery patients

Intervention for UC

-Decreasing diarrhea: Drug & nutrition tx; Rest; monitor perianal skin -Meds: 5-ASA's; Glucocorticoids; Antidiarrheal; Immunomodulators -Nutrition: NPO for bowel rest; TPN; Dietary aggravators -Surgery: a. Temporary or permanent ileostomy ******b. Ileostomy output after surgery is loose dark green & >1 L per day; apps. 1 week to slow down & eventually changes to paste-like, yellow-green c. Patients with internal pouch can have burning w/defecation; omit foods that cause gas -Skin care is priority! -Minimize pain -Monitor Lower GI bleeding

It is found that the patient has a small fecal impaction. Document the preventive care that the nurse would include in patient/family teaching for this patient.

-The nurse would need to teach the patient/family about dietary changes. The patient should be eating foods high in fiber including plenty of raw fruits and vegetables and whole grain products. Also encourage patient to push fluids, esp. water. -The nurse should also discourage excessive use of laxatives. It can make the body dependent on them and can also contribute to an atonic colon. -Encourage the patient and the family to become more physically active. Daily walks can help to encourage gut motility and peristalsis and well as many other health benefits. -Teach patient to take bulk-forming products such as Metamucil to provide fiber. -Use natural foods to stimulate peristalsis, such a prune juice or warn beverages like coffee or tea. -Teach patient and family to report any abdominal pain or distention with or with out constipation because this could be an indication of recurrent obstruction.

Diverticular Disease cont'd

-Tx with diet & meds; -clears until sx subsides, then high-fiber, low-fat, spasmodics; -CT-guided percutaneous drainage of abscesses if needed, -one-stage resection or multiple-stage procedures -Meds: Antibiotics, pain meds maybe -Avoid laxatives & enemas - increase motility Rest is important -Surgery if rupture, peritonitis, obstruction or abscess (colon resection with or without colostomy)

Once the patient with abdominal trauma has been assessed for airway and breathing and circulation, focus on the risk for hemorrhage, shock, and peritonitis. Mental status, vital signs, and skin perfusion are priority nursing assessments with skin perfusion being the most reliable clinical guide in assessing hypovolomic shock Describe how patients present while in shock

-in a person with mild shock, the skin is pale, cool, and moist -With moderate shock, diaphoresis is more marked and urine output ceases -with sever shock changes in mental status are manifested by agitation disorientation and recent memory loss

Key features of peritonitis

-rigid, board like abdomen (classic) -Abdominal pain (localized, poorly localizes, or referred to the shoulder or chest -distended abdomen -N/V, anorexia -diminishing bowel sounds -inability to pass flatus or feces (obstipation) -Rebound tenderness in the abdomen -high fever, tachycardia -dehydration from high fever (poor skin turgor) -decreased urine output -hiccups -possible compromise in respiratory status

Patients with obstructions below duodenum but above colon have no ________compromise

Obstructions below duodenum but above colon have no ABG compromise

Other Meds for IBS

Other meds: -Xifaxan (Abtx) -TCA's (affect serotonin levels - slow gut transit) -anticholinergics (decrease spasms) -muscarinic antagonists (slow transit) -probiotics *Nursing - provide good education, chew slowly, no ETOH/cigarettes

Name that obstruction -initial sx crampy pain wavelike & colicky -LOTS of vomit - eventually fecal material (metabolic alkalosis) -pt gets NGT, maybe surgery -abdominal discomfort or pain possibly accompanied by visible peristaltic waves in upper and middle abdomen -upper and epigastric abdominal distention -obstipation -sever F&E imbalances *METABOLIC ALKALOSIS

Small bowel obstruction

Malabsorption

The inability of the digestive system to absorb one or more of the major vitamins, minerals, and nutrients *Conditions: -Mucosal (transport) disorders -Infectious disease -Luminal disorders -Postoperative malabsorption -Disorders that cause malabsorption of specific nutrients

Tumors in rectosigmoid are associated with

hematochezia (blood in the stool), straining during defecation, narrow stools and dull pain

severe pain that stops & changes to tenderness on palpation may signal

perforation - report quickly!!

N/V BEFORE pain may be _______________ Pain BEFORE N/V may be _________________

N/V BEFORE pain may be gastroenteritis Pain BEFORE N/V may be appendicitis

The health care provider obtains an abdominal CT scan as soon as an obstruction is suspected. Distention with fluid and gas in the small intestine with the absence of gas in the colon indicates an obstruction in the______________

small intestine

Irreducible Herniation

(incarcerated) -Cannot be reduced or placed back in abd. cavity ***Requires immediate surgical intervention...could be strangulated

Diverticular disease for home

***Educate about diet: High-fiber for diverticulosis, avoid fiber when diverticulitis is present -If surgery: incision care, ostomy care -Educate about s/sx of acute diverticulitis

Diverticular Disease continued

***With diverticulitis, symptoms include mild or severe pain in lower left quadrant, possible distention, nausea, vomiting, fever, chills, and leukocytosis. **May have peritonitis - monitor for sepsis/shock **If diverticulum perforate, can have massive bleeding (very vascular) -Ask regarding the onset and duration of pain, and past and present elimination patterns. ASK ABOUT BOWEL PATTERNS -Nutrition and dietary patterns including fiber intake. -Inspect stool and monitor for symptoms potential complications.

Perineal Wound Care

***pain, comfort, and skin integrity are really important*** A. Wound care: -Place an absorbent dressing (e.g. abdominal pad) over the wound -Instruct the patient that he or she may use a feminine napkin as a dressings and to wear jockey-type shorts rather than boxers B. Comfort measures: -If prescribed, soak the wound in a sits bath for 10 to 20 minutes 3 to 4 times per day or use warm/hot compresses or packs -Administer pain medication as prescribed, and assess its effectiveness -Instruct that patient about permissible activities. The patient should: 1. assume a side-lying position in bed; avoid sitting long periods 2. Use foam pads or a soft pillow to sit on whenever in a sitting position 3. AVOID the use of air rings or rubber donut devices C. Prevention of Complication -Maintain fluid and electrolyte balance by monitoring intake and output and by monitoring output from the perineal wound -observe incision integrity and monitor wound drains; watch for erythema, edema, bleeding, drainage, unusual odor, and excessive or constant pain

Special Skin care for patients with chronic diarrhea

*Chronic diarrhea is a classic symptom of malabsorption -use medicated wipes or remoistened disposable wipes rather than toilet tissue to clean the perineal area -clean the perineal area with mild soap and warm water after each stool; rinse soap from the area well -If the physician allows, provide a sits bath several times per day -Apply a thin coat of A+D ointment or other medicated protectives barrier such as aloe products after each stool -keep the patient off the affected buttock area -for open areas cover with then duodenum or tegaderm occlusive dressing to promote rapid healing -observe for fungal or yeast infections, which appear as dark red rashes with satellite lesions. Obtain prescription for medication if this problem occurs

Interventions for intestinal obstructions

*Interventions are aimed at uncovering the cause and relieving the obstruction. Intestinal obstructions can be relieved by non surgical or surgical means. If the obstruction is partial and there is no evidence of strangulation, non surgical management may be the treatment of choice. -Nonsurgical - NPO, NGT (Salem sump) to allow venting of air and suction of contents. NGTs also allow decompression of the bowel by draining fluid and air. The Tube is attached to suction. -assess at least q4 for patency, placement, skin, output, may have to irrigate; is pt. passing gas? -NV?; -if lower obstruction: enemas, disimpaction -Replace IVFs, monitor F&E -May have TPN or PPN if pt. has chronic nutritional deficiencies or NPO for a longer time -Surgical - exploratory lap (open vs. MIS); pts. Will have NGT - clears to encourage peristalsis

Manifestations of colorectal cancer

*Manifestations may include: change in bowel habits (consistency or shape); blood in stool—occult, tarry, rectal bleeding; anemia, tenesmus; symptoms of obstruction; gas pains, either abdominal or rectal, feeling of incomplete evacuation (never get it all out). -Treatment depends upon the stage of the disease ***Metastasize can happen; liver most common site (bone liver and brain are sites of Mets) a patient with Mets in the liver would have jaundice, bruising, fatigue, bone pain, unexplained breaks..brain METS affect memory and confusion

Assessment of Intestinal Obstruction

-Ask about past hx of GI disorders, surgeries, and treatments -N/V? (Would mostly have this in the small bowel; metabolic alkalosis) *Pain assessment - severe pain that stops & changes to tenderness on palpation may signal perforation - report quickly -Singultus (hiccups) common -Keep pt. NPO until seen by MD

Other interventions

-Assessment and treatment of pain/discomfort -anticholinergic medications prior to meals, analgesics, -positioning, diversional activities, and prevention of fatigue -Fluid deficit, I&O, daily weight, assessment of symptoms of dehydration/fluid loss, -encourage oral intake, measures to decrease diarrhea -Optimal nutrition -elemental feedings that are high in protein and low residue or PN may be needed -Reduce anxiety; calm manner, allow patient to express feelings, listening, patient teaching

Treatment for malabsorption

-Avoid aggravating substances -Nutritional supplementation -Medications dependent on causes of malabsorption (antibiotics, anti-diarrheals, anti-cholinergics before meals) -Skin protection if irritated by diarrhea -Avoid PO supplemention because they aren't absorbing things well...maybe a powder form that they can mix with a liquid would absorb more

An 80-year-old man comes to the emergency department reporting acute upper to mid- abdominal, sporadic pain and cramping. Upon assessment, the nurse observes abdominal distention and high-pitched bowel sounds. The physician has ordered flat plate and upright abdominal x-rays that show distention of loops of intestine, with fluid and gas in the small intestine in conjunction with absence of gas in the colon. The physician has diagnosed a bowel obstruction. 1. Based on the findings, identify which type of bowel obstruction this patient most likely has.

-Based on the assessment findings I would conclude that the patient has a mechanical obstruction in the small intestine. I chose mechanical instead of non-mechanical because patients with mechanical obstructions have mid-abdominal pain or cramping that can be sporadic, just like our patient. While non-mechanical obstructions have pain that is described as a constant, diffuse discomfort. -I also decided it was mechanical because upon auscultation the nurse heard high-pitched bowel sounds. This finding is congruent with "cramping early in the obstructive process as the intestine tries to push the mechanical obstruction forward" (pg.1158) -Lastly I decided that the location of the obstruction was in the small intestine because the flat plate and upright abdominal x-rays show distension with fluid and gas in the small intestine with the absence of gas in the colon; this is a sign that that the obstruction is in the small intestine.

2. What other signs and symptoms would the nurse observe for in the patient with a small bowel mechanical obstruction?

-Because it is a small bowel obstruction the nurse should assess for visible peristaltic waves in the upper and middle abdomen, nausea and early, profuse vomiting (may contain fecal matter), failure to pass stool or flatulence (obstipation), severe fluid and electrolyte imbalance (daily weights are the best indicator), and metabolic alkalosis. (Chart 56-5) -The nurse should also assess for strangulation. If strangulation is present, "the pain becomes more localized and steady" (1158). -Assess for bowel sounds, distention, and the passing of flatulence at least twice a day.

Nonsurgical management has been selected for this patient, and he may return home after receiving special instructions. Identify a key factor, based on your assessment, on which the nurse would need to instruct him.

-Because the young man is a body builder I would put great enfaces on the fact that he should rest during the acute phase of illness and refrain from lifting, straining, coughing, or bending to avoid an increase in intra abdominal pressure which can result in perforation of the diverticulum. (1187). -I would also encourage him to eat a low fiber diet with clear liquids and educate him on the importance of taking all of his antibiotics.

Maintaining normal elimination pattern

-Identify relationship between diarrhea and food (food diary), activities, or emotional stressors -Provide ready access to bathroom/commode -Encourage bed rest to reduce peristalsis -Administer medications as prescribed -Record frequency, consistency, character, and amounts of stools so they can identify exacerbation

Identify the most likely interventions for this 80 year old patient with a small bowel mechanical obstruction

-Because there is no sign of strangulation, non-surgical management would probably be the treatment of choice. Our patient would be put on an NPO status and have a NG tube connected to suction to help decompress gas and fluid. Preferably a Salem sump tube because it stops the stomach mucosa from being pulled away during suction. -The nurse should also question the patient about passing flatulence, and the type/character of daily bowel movements. Flatus or stool meant that peristalsis has returned. (1159) -The patient should also have an IV started for fluid replacement. A lot of his electrolytes will be out of balance due to vomiting and/or nasogastric suctioning. But we must be careful when replacing his fluids. Because he is older he is more susceptible to fluid volume overload. -A few ice chips may be allowed if the patient is not having surgery and if the physician allows it. -The nurse should assist the patient into the semi fowler position to help alleviate the pressure of abdominal distension on the chest. She should also turn him frequent to promote peristalsis.

Strangulated Herniation

-Blood supply cut off by pressure from hernia ring; LIFE THREATENING -Leads to ischemia & obstruction, possibly necrosis & perforation! -S/SX = abdominal distention, N/V, pain, fever, tachycardia

Appendicitis Cont'd

-CBC shows leukocytosis (elevated WBCs) with shift to left, abdominal xrays/CT/us -Major comp is perforation, which can lead to peritonitis, abscess, or portal pylephlebitis -Older adults do not present same way (99 may be a huge fever for them...our low grade is their high grade) - have higher mortality; higher rate of perforation -Tx with surgery -Nursing - pre/post-op -Keep patients NPO -Appendectomy: uncomplicated can be done laparoscopic; if complicated or suspected peritonitis will be done open -If open technique, patients may have drains, NGT for decompression, IV antibiotics

Nursing Considerations for intestinal obstructions *Know this slide

-Can have F & E imbalances *Obstructions high in small intestine = metabolic alkalosis *Obstructions below duodenum but above colon - no ABG compromise *Obstructions lower in intestine = metabolic acidosis *Major Fluid imbalance = hypovolemia...replace fluids and electrolytes

Diverticular Disease

-Diverticulum: sac-like herniations of the lining of the bowel that extend through a defect in the muscle layer -May occur anywhere in the intestine but are most common in the sigmoid colon A. Diverticulosis: multiple diverticula without inflammation B. Diverticulitis: infection and inflammation of diverticula C. Diverticular disease increases with age and is associated with a low-fiber diet ( we all have a low fiber diet) -Diagnosis is usually by colonoscopy -Patients may have chronic constipation preceding development of diverticulosis, frequently asymptomatic but may include bowel irregularities, nausea, anorexia, bloating, narrow stools, and abdominal distention

IBD ASSESSMENT

-Health history to identify onset, duration and characteristics of pain (LOCATION), diarrhea, urgency, tenesmus, nausea, anorexia, weight loss, bleeding, and family history -Discuss dietary patterns, alcohol, caffeine, and nicotine use -Assess bowel elimination patterns and stool (how many stools a day?) -Abdominal assessment ******For UC: VS are usually WNL; fever indicates infix ******For Crohn's: low-grade fever common; higher fever happens with fistulas, abscesses & severe inflammation

Assessment & Labs for colorectal cancer

-Health history, including family hx & risk factors -New onset Fatigue and weakness -Abdominal or rectal pain -Nutritional status and dietary habits (should avoid high fat refined meat ) -Elimination patterns -Abdominal assessment (distended, high pitched sounds) -Characteristics of stool (tarry, bloody, no stool at all) -Most common signs are rectal bleeding, anemia & change in stool consistency &/or shape **Labs: H&H, positive FOBT (negative doesn't necessarily mean "negative") Imaging: CT, MRI, barium, endoscopic with biopsies

Mr. Moore tells the nurse that he has a frequent sensation of "gas pain" and that he has been growing increasingly tired within the past 6 months. Although his job as an attorney requires that he be seated much of the time, he is finding it difficult to get through a normal workday without becoming exhausted. The primary care provider examines Mr. Moore and orders a series of diagnostic tests. 2. What types of diagnostic tests would be appropriate to gather more information about Mr. Moore's condition

-I think that he would need a CBC to determine an infection and or anemia. He would also need some kind of endoscopic procedure to determine where the bleed is coming from, if the area is perforated, and to help find ulcers, colon polyps, tumors, and/or areas of inflammation. The patient would also require a MRI to determine if there are any masses or lesions. Lastly we would need to know his PT/INR levels to determine his ability to clot.

Mr. Moore is a 54-year-old man with a past medical history of hypertension, seasonal allergies, and arthritis. As a young adult, he began smoking in his early 20s and quit when he was 50 years old. He lives with his wife of 30 years and they have two grown sons. He is being seen today at a local clinic because he states that he has had blood in his stool for 2 months, and he decided it was time to have it checked out. 1. What further assessment questions should the nurse ask Mr. Moore?

-I would ask him to tell me more about his smoking history (how many packs a day, history of quiting, etc.). I would do this because smoking is a major risk for GI cancers. -I would then ask him about his bowel patterns: constipation, diarrhea (how much), fecal continence, change in bowel patterns, characteristics of stool, jaundice, last bowel movement, "did you eat something new or something that aggravates your stomach" -I would assess his history of GI surgery or problems, weight patterns, and medication use.**Goodie powders can cause a massive GI bleed and large amounts of aspirin or NSAIDs can predispose the patient to peptic ulcer disease and GI bleeding. -Lastly I would ask him about his alcohol intake and his travel history. (drinking is harmful to the GI tract and depending on where he traveled he could have acquired a food borne infection causing his GI issues.

3. The patient says, "Oh, I'll just go home and take a laxative or an enema and I'll be fine." Explain why these should be avoided.

-I would strongly discourage my patient from using laxatives or enemas. I would reassure him that his disorder can be controlled by a proper diet. I would also warn him that using laxatives or enemas during acute attacks can make the pain worse. Lastly I would teach him that his body could become dependent upon them and over time he wouldn't be able to eliminate without them.

Abdominal Trauma

-Injuries to structures located between diaphragm & pelvis -Blunt or penetrating ***AFTER ensuring ABC's - abd. assmnt. -May see distention, ecchymosis, auscultation, dullness on percussion can indicate presence of blood or fluid, light palpation can ID areas of tenderness, rigidity, etc. -Pts. Without obvious s/sx bleeding or peritoneal irritation may have diagnostic peritoneal lavage and CT; some will have immediate surgery -patients will be in ICU with hemodynamic monitoring including intra-abdominal pressure monitoring (normal is 0-5 mmHg); prevention is key Can have a compartment syndrome Severe traumas will have exploratory surgery

Peritonitis

-Life-threatening, acute inflammation & infection of visceral/parietal peritoneum -Most often caused by contamination of cavity by bacteria or chemicals (bile, pancreatic enzymes) -Untreated leads to continued and progressive inflammation with significant fluid volume loss from circulatory system (hypovolemia and shock); peristalsis slows or stops; can lead to sepsis -Patients are usually acutely ill: pain, tenderness, distention are cardinal signs; -WBC count elevated, F&E status (BMP, H&H) -Abdominal pain poorly localized

Nursing Care of the Post op patient having minimally invasive inguinal hernia repair (MIIHR)

-Monitor vital signs, esp blood pressure for indications of internal bleeding -Assess and manage incisional pain with oral analgesics; report and document severe pain that does not respond to drug therapy immediately -Encourage deep breathing after surgery, AVOID excessive coughing -Encourage ambulation with assistance as soon as possible after surgery (within the first few hours) -Apply ice packs as prescribed to the surgical area -Assist the patient to void by standing the first time after surgery (Men w/inguinal repair may have trouble voiding immediately following surgery) ***Teach patients at discharge to: a. rest for several days after surgery b. observe the incision sites for redness or drainage, and report these findings to the surgeon c. Shower after 24 to 36 hours after removing any bandage (do no remove Steri-Strips); be aware that the Steri-Strips will fall off in about a week d. monitor temperature for the first few days, and report the occurrence of fever e. do not lift more than 10 pounds until allowed by the surgeon f. avoid constipation by eating high fiber foods and drinking extra fluids, can use stool softener too -return to work when allowed by the surgeon usually in 1 to 2 weeks depending on the patients work responsibilities **Post-op: If O.P. patient will need someone to drive home; if open, patient will be hospitalized for few days; activity may be limited, pain management, watch for s/sx infection, try to avoid coughing - but other respiratory interventions are encouraged -patients taking opoids should not drive or lift heavy machinery ***Teach patient to observe for redness, swelling, heat, drainage, and increased pain and promptly report these to the provider AVOID Coughing (surgeons usually allow them to return to their usually activities after surgery with avoidance of straining and lifting for several weeks while subcutaneous tissues heal and strengthen.

Appendicitis

-Most common cause of RLQ pain; young adults -Empties inefficiently & has small lumen, it's prone to obstruction & inflammation -Inflammatory process increases intraluminal pressure → localized pain in RLQ → appendix fills with pus -Vague epigastric or periumbilical pain progressing to sharp a. RLQ pain; low-grade fever, N/V, anorexia b. McBurney's point tenderness, rebound tenderness is the sight of pain c. pain can also be in the lumbar or pelvic regions d. pain on defecation or urination, Rovsing's sign aka pain on defecation or urination **Can progress rapidly to perforation and peritonitis; life threatening **Temp >101 and tachycardia; sepsis within 24-36 hrs

Gastroentritis

-N/V/D as a result of inflammation -Viral or bacterial (Norovirus leading cause of gastroenteritis) -Usually process is self-limiting and lasts about 3 days **HANDWASHING AND SANITIZATION OF SURFACES! -Ask about travel, foods eaten in past 24 to 36 hours -Fluid replacement is essential; monitor hydration status, F&E in older adults; typically do not give drugs that suppress intestinal motility to allow the organism to be expelled -May give abtx, teach skin care, hand hygiene

Irritable Bowel Syndrome

-No known cause, more common in women, very common -Functional disorder of intestinal motility -Either increased or decreased transit **4 classifications: Constipation, Diarrhea, Alternating, or Mixed A. Assessment: -Changes in bowel patterns? -Any GI infection? -Medications? -What foods aggravate it? Stress? -Caffeinated drinks or artificial sweeteners? B. Symptoms vary: -altered bowel patterns, bloating, distention -maybe nausea, common report: pain in LLQ ***Symptoms precipitated by eating, relieved by bowel movement -Genetic, hormonal, and stress factors can all cause IBS -Women are twice as likely to get IBS than men ***usually left lower quadrant pain***** -Patients may "look healthy" with stable F&E and labs

Colostomy Care Basics

-Normal appearance of stoma (should be reddish pink and moist and protrude about 3/4 inch (2cm) from the abdominal wall *The colostomy should start functioning in 2 to 3 days post op -Signs and symptoms of complications -Measurement of stoma -Choice, use, care, application of appropriate appliance to cover stoma -Measures to protect skin -Dietary measures to control gas and odor -Resumption of normal activities including work, travel, and sexual intercourse

Herniation Assessment

-Pt. usually reports "lump" or a protrusion felt at the involved site (The development of the hernia may be associated with straining or lifting) -Have patient lie down and stand for inspection **If the hernia is reducible, it may disappear when the patient is lying flat -Auscultate for active bowel sounds - Absence may indicate obstruction & strangulation (emergency!) **NEVER forcibly apply pressure to hernia site - can cause strangulation and/or rupture

Interventions for Crohns disease

-Similar to UC -Meds: a. Mild to moderate - 5-ASA's b. Moderate to severe - immunosuppressants c. Biologic response modifiers- suppress TNF-alpha d. Glucocoriticoids e. Flagyl for infx -Nutrition: TPN for exacerbations...to rest the gut; Supplements ****Fistula management: nutrition & electrolyte tx, skin care, infix prev.; At least 3000 cals/day (they need so much because they are malabsorbed); Skin protection is priority; May need wound vac; Watch for s/sx infx - patient will have antibiotic tx -Surgery not as successful

What community-based care will the nurse incorporate for the care of this patient?

-Teach the patient to avoid alcohol and food containing seeds e.g. figs, tomatoes, strawberries, watermelon, etc. Also teach patient that fat intake should not be more than 30% of daily caloric intake. -Teach patient to avoid fiber when symptoms of diverticulitis are present. -Advise him to avoid laxatives and enemas except for Metamucil. -If patient is interested in information about other community resources, remind the patient to contact the United Ostomy Associations of America (www.uoaa.org)

A hernia is strangulated when the blood supply to the herniated segment of the bowel is cut off by pressure from there hernial ring (the band of muscle around there hernia). If a hernia is strangulated, there is ischemia of the bowel and possible bowel perforation. Signs of strangulation are....

-abdominal distention -N/V -Pain -Fever -Tachycardia

Nursing care of patients who have an intestinal obstruction

-monitor vital signs, especially blood pressure, for indications of fluid balance -assess the patients abdomen at least twice a day for bowel sounds, distention, and passage of flatus -monitor fluid an electrolyte status including lab values -manage the patient who has a NGT: a. monitor drainage b. ensure tube patiency c. check tube placement d. irrigate tube as prescribed e. maintain the patient NPO status f. provide frequent mouth and nares care g. maintain the patient in semi fowlers position -give analgesics for pain as prescribed -give alviompan as prescribed for patients with post op illeus -maintain TPN if prescribed

Reducible Herniation

-non surgical Contents can be placed back into abdominal cavity by gentle pressure Ex. If it's a result of heavy lifting or pregnancy you can usually reduce that back

The next morning the patient is scheduled for surgery to remove the tumor and place a sigmoid colostomy. He returns to the unit with a clear ostomy pouch system in place. The stoma appears healthy. 1. How would the nurse document this finding? 2. How soon postoperatively would the nurse expect the colostomy to begin functioning?

1. "Reddish pink, moist, and protrudes about 2 cm from the abdominal wall." Initially the stoma may be slightly edematous and there may a small amount of bleeding. 2. About 2 to 4 days postoperatively.

What are the 5 types of Herniation

1. Indirect inguinal (most common type, usually in men)...more in the scrotal area) 2. Direct inguinal (think older adults) 3. Femoral 4. Umbilical (either congenital which appear in infancy or acquired...obesity, pregnancy) 5. Incisional

What are the three classifications of Herniation

1. Reducible 2. Irreducible 3. Strangulated

A nurse is caring for a client following a laparoscopic hernia repair surgery. Which assessment finding would the nurse report to the surgeon immediately a. Severe abdominal pain b. blood pressure of 140/86 c. respiratory rate of 26 breaths per minute d. mild abdominal distension

A. Severe abdominal pain * Soreness and discomfort is common but severe acute pain needs to reported

Following a MIIHR a urine output of less than ___ml should be reported to the surgeon

30 *A fluid intake of at least 1500 to 2500 ml daily prevents dehydration, maintains urinary function, and prevents constipation

Crohns anatomy, causes, manifestion, assessment, treatment

A. Anatomy: Can be the small intestine (most often), the colon, or both. The book even states it can start from the mouth to the anus but most often affects the terminal ileum. B. Causes: Exact cause is unknown. It's expected genetic, immune, and environmental factors may contribute to its development. C. Manifestations/ Assessment: Presents itself as inflammation that causes a thickened bowel wall. Strictures and deep ulcerations also occur. Malabsorption is biggest concern. Assess for distention, masses, or visible peristalsis. Bowel sounds may be diminished or absent in severe cases. -Low grade fever, diarrhea, abdominal pain. Anemia is a common symptom both due to bleeding and poor nutrition. Serum levels of folic acid and B12 are usually low. D. Treatment: Drug therapy is very similar to UC. In severe cases, inpatient treatment involving TPN. High risk for fistula development (Bowel → Bladder) which can lead to sepsis. Will need high calorie diet (supplemental nutrition) to heal.

Gastroenteritis: anatomy, manifestations, cause, treatment

A. Anatomy: Mucous membranes of the stomach and intestinal tract (primarily small bowel). B. Causes: Most common is viral. Norovirus is the culprit. It is transmitted through the fecal-oral route, incubation is 1 to 2 days. It is hell on Earth. C. Manifestations/ Assessment: N/V/D and in severe cases where it infects the young, elderly, or immunocompromised, severe dehydration and hypovolemia. For both demographics, the excessive loss of electrolytes can be serious. -Inquire if they have traveled outside the country (Mexico, Asia, Africa, etc.) and if they have eaten at any local restaurants. Bacterial infection can come from contaminated spinach, lettuce, or other produce in the U.S. D. Treatment: Encourage fluid replacement and oral rehydration therapy. Do not use drugs that suppress intestinal motility (You're trying to get rid of it, don't bulk it up!). Antiemetic can be used for comfort. For bacterial infection, an antibiotic will be needed. For viral, it should pass within 48 hours.

Diverticular Disease: Anatomy, cause, manifest ions, assessment, treatment

A. Anatomy: Muscular wall of any portion of the gut but most commonly the colon. **Diverticulosis - Presence of many abnormal pouch like herniation's in the wall of the intestine. **Diverticulitis - Inflammation of diverticula. B. Causes: Usually develops at points of weakness in the intestinal wall, often at areas where blood vessels interrupt the muscle layer. Weakness develops either by aging or lack of fiver in diet. -Without inflammation, diverticula causes few problems. If bacteria/food gets trapped in the pouch, then it develops into diverticulitis. C. Manifestations/ Assessment: Diverticulosis = No symptoms. Usually found in routine colonoscopy. Diverticulitis may have abdominal pain in the LLQ. N/V and low-grade fever. Elevated WBC. D. Treatment: Usually treated on an ambulatory care basis. Assess for prolonged fever, pain, or blood in stool. Broad spectrum antibiotics. Acute care may involve IV fluids to correct dehydration, IV antibiotics. Surgery needed if it leads to rupture of diverticulum. Requires colon-resection.

Peritonitis: anatomy, causes, manifestion/ assessment, labs, diagnostics, treatment

A. Anatomy: Peritoneum and endothelial lining of the abdominal cavity. B. Causes: Perforation (Internal/External) → Bacteria → Inflammation. -Can be any number of factors that can create a perforation thus leading to this issue. -This is life-threatening. Can lead to hypovolemic shock, bacteremia, or septicemia. C. Manifestations/ Assessment: has many key features. Big ones include rigid, board like-abdomen (classic sign), distended abdomen, N/V, diminishing bowel sounds, high fever, tachycardia, decreased urine output, compromised respiratory status. D. Labs/Diagnostics: WBC, blood cultures, BUN, creatinine, H&H. Abdominal x-ray series. E. Treatment: Patient is hospitalized because of the severe nature of the illness. Hypertonic IV fluids, broad-spectrum antibiotics, NG tube to decompress stomach, NPO. Abdominal surgery may be needed to repair cause if above does not work.

Appendicitis: anatomy, causes, manifestations, assessment, risk factors, diagnostics, treatment

A. Anatomy: Pouch on the colon that has no known purpose. Just below the ileocecal valve. B. Causes: Blockage →Bacteria → Inflammation. Usually by hard feces, but can be from malignant tumors, worms, etc. C. This is life-threatening. Gangrene and sepsis can occur within 24-36 hours. Perforation can develop within 24 hours from onset. D.Manifestations/Assessment: Abdominal pain followed by N/V can indicate appendicitis (The opposite usually indicates gastroenteritis). Pain is usually in the RLQ. E. Risk Factors: Age, family history, and intra-abdominal tumors. F. Diagnostics: An ultrasound study may show the presence of an enlarged appendix. G. Treatment: All patients suspected or confirmed appendicitis are hospitalized and surgery is required ASAP. It is a MIS procedure (laparoscopy). There is another procedure that requires no incision called NOTES. Post=surgery, early ambulation, IV antibiotics, inpatient stay for 3 to 5 days.

Ulcerative Colitis: Anatomy, causes, manifestations/assesment, treatment

A. Anatomy: Usually the rectum and sigmoid colon but can consist of the entire colon depending on how advance the disease is. B. Causes: Exact cause is unknown but it is anticipated that genetics, immunologic, and environmental factors likely contribute to disease development. With long-term UC comes with increased risk for colon cancer. C. Manifestations/ Assessment: Obtain family history and nutrition history. Ask about bowel elimination patterns, NSAID use, travel, etc. - is very useful for separating the different severity levels of the disease. -In mild forms, they can be symptomatic and labs/vitals normal. In fulminant they may require a blood transfusion and have a fever, tachycardia, abdominal pain, anemia, etc. D. Treatment: In mild forms, can include drug therapy. In severe forms it can include surgery. Pretty complicated subject matter but read through the pages above. I know, what a cop out.

What are the four different classifications of IBS? Goals of IBS?

A. Constipation, Diarrhea, Alternating, or Mixed B. Goals: -to relieve pain (usually in left lower quadrant) -maintain fx bowel pattern -avoid foods that are irritants -High-fiber (30-40 G/day) -adequate hydration -exercise

3 types of intestinal obstructions

A. Intusussception : a medical condition in which a part of the intestine invaginates (folds into) into another section of intestine, similar to the way the parts of a collapsible telescope retract into one another. B. Volvulus: is when a loop of intestine twists around itself and the mesentery that supports it C. Hernia: the exit of an organ, such as the bowel, through the wall of the cavity in which it normally resides

Mechanical vs Functional Obstruction

A. Mechanical obstruction - many causes such as tumors, chrons disease, obstructive adhesions from previous surgeries -in mechanical obstruction, the bowel is physically blocked by problems outside the intestine (e.g. adhesions), in the bowel wall (e.g. crohns disease), or in the intestinal lumen (e.g. tumors) * patient present with mid-abdominal pain or cramping that can be sporadic *Mechanical colonic obstruction causes a milder more intermittent colicky abdominal pain than is seen with small bowel obstructions *high-pitched bowel sound are also heard in a mechanical obstruction; "cramping early in the obstructive process as the intestine tries to push the mechanical obstruction forward" B. Functional obstruction/non-mechanical - paralytic ileum (post op patients are high risk) *Patients have pain that is described as a constant, diffuse discomfort. -Does not involve a physical obstruction in or outside the intestine. Instead peristalsis is decreased or absent as a result of neuromuscular disturbance resulting in a slowing of the movement or a backup or intestinal contents.

Peritonitis treatment

A. Non-surgical mgmnt: -Hypertonic IVF, Broad-spectrum IV AbTx, strict I&O because they are at risk for fluid volume loss, (urinary output can also tell us if they are going into sepsis) NGT, NPO O2, analgesics B. Surgical mgmnt: -Exploratory laparotomy with irrigation of peritoneum with antibiotic solution -Patient may come back to floor with drains to be used for irrigation -Irrigation is STERILE, have to count this as I&O, does patient retain any of irritant? A. Community-based considerations -Monitor for s/sx infx; dressing changes & irrigations, med teaching; no lifting for 6 weeks *If there is a GI pateint (inflammatory or non inflammatory) it CAN lead to Peritonitis

Interventions for colorectal cancer

A. Preparing the patient for surgery -Emotional support B. Providing postoperative care -Pain management, ambulation, respiratory measures, -Maintaining optimal nutrition - NGT to clears and progress as tolerated, laparascopic - usually have solids earlier C. Providing wound care: surgical & ostomy -Monitoring and managing complications -Removing and applying the colostomy appliance -Irrigating the colostomy - esp. if sigmoid -Supporting a positive body image -Discussing sexuality issues **Promoting home and community-based care

Inflammatory Bowel Disease (IBD

A. Ulcerative colitis: -DEFINED BY MULTIPLE ULCERATIONS, diffuse inflammations & shedding of colonic epithelium -Exacerbations/ remissions, BLOODY DIARRHEA, mucus & pus, -LLQ PAIN RELIEVED BY DEFECATION, tenesmus, rectal bleeding, ****10-20 liquid stools/day, anemia, low H&H, WBC/ESR up, low albumin, skin care B. Crohn's disease (regional enteritis) See COBBLESTONE APPERANCE on barium enema, flare-ups; at risk for fistulas; most patients need surgery at some point; worsened by bacterial infx Insidious, RLQ PAIN, diarrhea, CRAMPS ESP AFTER EATING, abd. tenderness, DONT EAT-LOSE WEIGHT anemic, steatorrhea, decreased H&H, WBC/ESR up, albumin down -Is chronic,no cure

Inflammatory Bowel Disease (IBD): Ulcerative colitis vs Crohns disease

A. Ulcerative colitis: -begins in the rectum and precedes in a continuous manner toward the cecum -peaks from 15-25 yr and 55- 65 yr **10-20 liquid, bloody stools a day -Complications: hemorrhge, nutritional deficiencies -infrequent need for surgery B. Chrons Disease: -Most often in the terminal ileum, with patchy involvement through all layers of the bowel -peaks between 15-40 yr -5-6 soft, loose stools per day, NON-BLOODY -fistulas are common, nutritional deficiencies *FREQUENT need for surgeries

Home Care Colostomy

A. assess GI status including: -dietary and fluid intake and habits -presence or absence of N/V -Weight gain or loss -Bowel elimination pattern and characteristics and amount of effluent (stool) -Bowel sounds B. Assess condition of stoma including: -location, size, protrusion, color, integrity -signs of ischemia, such as dull coloring or dark or purplish bruising C. Assess peristomal skin for: -presence or absence of excoriated skin, leakage underneath drainage system -fit of appliance and effectiveness of skin barrier and appliance D. Assess the patients and families coping skills including: -self care abilities in the home -acknowledgement of changes in body image and function -sense of loss

Intestinal Obstruction: Small bowel vs Large Bowel

A.Small bowel -initial sx crampy pain wavelike & colicky -LOTS of vomit - eventually fecal material (metabolic alkalosis) -pt gets NGT, maybe surgery -abdominal discomfort or pain possibly accompanied by visible peristaltic waves in upper and middle abdomen -upper and epigastric abdominal distention -obstipation -sever F&E imbalances *METABOLIC ALKALOSIS B. Large bowel - may have lower abdominal distention & perforation -minimal or no vomiting *obstipation or RIBBON LIKE STOOL -No major F&E imbalances *METABOLIC ACIDOSIS (not always present) -slow development, shape of stool may be altered -colonoscopy, rectal tube, maybe surgery -intermittent lower abdominal cramping

Fiber and inflammation

A.When its inflamed DO NOT EAT FIBER B. When it is inflamed you want low fiber C. Diverticulous encourage HIGH FIBER

The nurse recognizes that which ethnic group has a higher incidence of colorectal cancer? Asian Caucasian Hispanic/Latino African-American

African-American men and women are diagnosed with and die from colorectal cancer at higher rates than men and women of any other United States racial or ethnic group. The reason for this is not yet understood

The patient is admitted to the acute medical unit. Which medication would the nurse question? A. Ibuprofen (Motrin) B. Mesalamine (Asacol) C. Prednisone (Deltasone) D. Loperamide (Imodium)

Answer: A Ibuprofen is a nonsteroidal antiinflammatory drug (NSAID); NSAIDs increase the risk for bleeding.

An older patient diagnosed with bacterial gastroenteritis reports abdominal cramping, diarrhea, nausea and vomiting, and fatigue for the past 24 hours. The nurse should monitor the patient for what priority assessment? A. Dehydration B. Hypokalemia C. Hypernatremia D. Perineal skin breakdown

Answer: A Rationale: In older adults, dehydration occurs with viral and bacterial gastroenteritis and may require hospitalization. Electrolyte imbalances are also common, especially hypokalemia and hypernatremia. The aging skin is also at risk of compromise from frequent exposure to enzymes in the stool.

The patient is discharged and home health services are arranged. What are the home health nurse's assessment priorities? (Select all that apply.) A. GI status B. Condition of the stoma C. Peristomal skin condition D. Patient and family's coping skills E. Results of daily laxative prescription

Answer: A, B, C, D The home health nurse's priorities are related to the patient's stoma care, GI status, and psychosocial status of the patient and family as a result of the surgery. Patients with a colostomy are often prescribed a stool softener, but usually not prescribed a laxative.

Later in the afternoon, the patient states that the abdominal pain is getting worse. Which nursing interventions are appropriate? (Select all that apply.) A. Providing sits baths as needed B. Administering analgesics as ordered C.T eaching music therapy or guided imagery D. Evaulting the diet for foods that cause pain E. Providing antidiarrheal medications if ordered

Answer: A, B, C, E Sitz baths will help prevent skin excoriation or irritation. Complementary therapies used in conjunction with analgesics can be very helpful in controlling pain. Antidiarrheal medications may provide symptomatic relief. Evaluating offending foods would not address the patient's immediate symptom of pain.

What priority laboratory analysis should the nurse review when caring for a patient with Crohn's disease? Potassium Hemoglobin Serum albumin C-reactive protein

Answer: B Rationale: Crohn's disease presents as transmural inflammation that causes a thickened bowel wall, strictures, and deep ulcerations that result in severe diarrhea and malabsorption of vital nutrients. Anemia is common, usually from iron deficiency or malabsorption issues. C-reactive protein may be monitored as a marker of inflammation, albumin to assess nutritional status, and potassium related to losses from diarrhea

What symptom does the nurse expect the patient with intussusception to exhibit? a. Decrease in pulse b. Singultus (hiccups) c. Frequent bloody stools d. Extremely elevated body temperature

Answer: B Rationale: Intussusception is a telescoping of the intestine within itself. Singultus (hiccups) is common with all types of intestinal obstruction. The vagus and phrenic nerves stimulate the hiccup reflex. Intestinal obstruction can increase the intraabdominal pressure, causing pressure on the phrenic nerve and the symptom of singultus (hiccups).

The patient is a 21-year-old who has recently been diagnosed with ulcerative colitis (UC). In the ED, she tells the nurse that she has been having 7 to 8 bloody stools daily. Upon assessment, the nurse finds that her heart rate is 120/min, and she has abdominal pain upon palpation. Laboratory results show a hemoglobin level of 9 g/dL. How is the severity of the patient's ulcerative colitis categorized? A. Mild B. Severe C. Moderate D. Fulminant

Answer: B Severe UC presents with greater than 6 bloody stools daily and may include fever, tachycardia, anemia, abdominal pain, and an elevated C-reactive protein and/or erythrocyte sedimentation rate (ESR).

The patient is preparing for discharge. She asks what is the best way to keep her skin from breaking down. What is the appropriate teaching the nurse will provide? A. "Add high-fiber or high-cellulose foods to your diet." B. "Apply a pectin-based skin barrier after each bowel movement." C. "Wash with mild soap and warm water after each bowel movement." D. "Take a laxative daily at bedtime to facilitate morning bowel movements."

Answer: C Good skin care after each bowel movement is the best way to protect from excoriation or irritation due to frequent bowel movements. Pectin skin barriers should only be used with ostomies. High-fiber or high-cellulose foods should be avoided, as should laxatives.

The patient's stool is positive for occult blood, and he is admitted to the inpatient oncology unit 3 hours later. Two hours after admission, the patient is passing bright red blood from his rectum. Where does the nurse anticipate that the patient's tumor may be located? A. Ascending colon B. Transverse colon C. Descending colon D. Rectosigmoid colon

Answer: D Tumors of the rectosigmoid colon are associated with hematochezia (the passing of red blood via the rectum). This tumor location is also associated with straining to pass stools and narrowing of stools. Additionally, the patient may report dull pain.

Three days later the stoma is functioning. What stool assessment does the nurse anticipate? A. Very little stool and mostly gas B. Diarrhea liquid stool C. Pasty stool D. More solid stool

Answer: D Immediate postoperative stool may be liquid, but it becomes more solid depending on the location of the colostomy. Stool from an ascending colon colostomy will be more liquid, stool from a transverse colon colostomy will be more pasty, and stool from a descending or sigmoid colostomy is more solid and similar to the usual stool expelled from the rectum.

At the oncologist's office, the patient tells the nurse that he has been experiencing vomiting and diarrhea. He states that he is tired all the time and has lost about 15 pounds over the past month. What is the priority diagnostic test that the nurse anticipates? A. Esophagogastroduodenoscopy (EGD) B. Colonoscopy C. Serum electrolytes D. Stool for fecal occult blood

Answer: D The most common signs of colorectal cancer are rectal bleeding and anemia.

The patient states, "I am afraid I'll never get to go out with my friends again because I can't be away from the toilet." Which is the appropriate nursing response? A. "What makes you say that?" B. "Your friends will understand." C. "I wouldn't worry about it if I were you." D. "It sounds like you are concerned about managing this disorder when you are out."

Answer: D This response verbalizes the implied concern. Response A does not address the concern and requires the patient to give an answer that defends her feelings. Responses B and C minimize the patient's feelings and do not address her concerns.

Surgical Treatment of a hernia MIIHR Pre op

Minimally invasive inguinal hernia repair *Nursing considerations: -Lots of education about procedure -NPO before for # of hrs indicated by MD -Usually done on outpatient basis for uncomplicated pts -If strangulation, may need resection or temporary ostomy ***Minimally invasive inguinal hernia repair (MIIHR) is the surgery of choice *Teach them NOT to strain or heavy lift or COUGH

Metastasize of colorectal cancer

CRC can metastasize by direct extension or by spreading through the blood or lymph. The tumor may spread locally into the four layers of the bowel wall and into neighboring organs -The liver is the most common site of metastasis from circulatory spread. -Metastasis to the lungs, brain, bones, and adrenal glands may also occur -Complication related to the increasing growth of the tumor locally or through metastatic spread include bowel obstruction or perforation with resultant peritonitis, abscess formation, and fistula formation to the urinary bladder or the vagina. -The tumor can cause frank bleeding and obstruction ***Metastasize can happen; liver most common site (bone liver and brain are sites of Mets) **a patient with Mets in the liver would have jaundice, bruising, fatigue! **A person with METS in the bone would have bone pain, unexplained breaks. **A person with METS in the brain would have memory issues and confusion

What is a classic symptom of malabsorption

Chronic diarrhea! *Monitor skin integrity -Steatorrhea common sign (quantitative fecal fat analysis will be elevated) -Decreased MCH (avg. Hgb in RBC), MCV (avg. size of RBC), and MCHC (concentration of Hgb in a volume of RBC - calculated by dividing Hgb by Hct) = microcytic anemia from iron deficiency -Increased MCV with variable MCH & MCHC = macrocytic anemia from B12 & folic acid deficiency -May see low serum Fe, cholesterols, Ca+, albumin, other Vitamins -Schilling test for B12 urinary excretion

An 18-year-old body-builder has just come into the office reporting left lower quadrant abdominal pain, constipation, and blood-streaked stool. On examination of the abdomen, the nurse observes slight distention and tenderness on palpation, especially in the left lower quadrant (LLQ). Vital signs are: heart rate, 77 beats/min; respiratory rate, 16 breaths/min; blood pressure, 120/70 mm Hg; temperature, 100.8° F (38.2° C). Based on complete blood count (CBC) results, the patient has an elevated white blood cell count, and his stool test for occult blood is positive. Diverticulitis is diagnosed. 1. Document key findings in your assessment using the focus charting method (also known as the DAR method—data, action, response).

D (Data): An 18-year-old body-builder has just come into the office reporting left lower quadrant abdominal pain, constipation, and blood-streaked stool. On assessment of the abdomen, the nurse notes slight distention and tenderness on palpation, especially in the left lower quadrant (LLQ). Patient is running a fever of 100.8° F (38.2° C), but all other vitals are within range. A (Action): Called the physician to notify him of the findings and he ordered a complete blood count which showed the patient has an elevated white blood cell count, and his stool test for occult blood is positive. Diverticulitis is diagnosed. I administer the prescribed mild analgesics for pain as well as a broad-spectrum antibiotic. I will also continue to monitor for fluid and electrolyte imbalance. Lastly I will administer the prescribed Tylenol for his fever. R (Response): Patient reported that his pain level had significantly decreased after 30 minutes and his fever has come down to 98.9 degrees Fahrenheit. There are no signs of fluid or electrolyte imbalance. Lab results following antibiotics are pending. Will continue to monitor closely.

What psychosocial implications of cancer, and of a permanent colostomy, might Mr. Moore experience?

He is probably feeling very scared and insecure about his diagnosis. I think his embarrassment is what led him to waiting so long to get it looked at. He is probably concerned about people finding out about his stoma, how to lead a normal live with a stoma, how to be intimate with his wife, etc. I would encourage him to discuss possible concerns in addressing and resolving these potentially stressful events. I would encourage him to go to a support group and or a therapist to help him work through his depression and anxiety related to the stoma and having cancer.

What would high pitched sounds upon auscultation of a distended abdomen indicate?

High pitched bowel sounds (borborygmi) which are associated with cramming in the obstructive process as the intestine tries to push the mechanical obstruction forward -Thus high pitched sounds could indicate a mechanical obstruction

A patient has recently been placed on corticosteroids as treatment for ulcerative colitis. The nurse should monitor the patient's laboratory results for evidence of which condition? Hyperkalemia Hypernatremia Hypercalcemia Hyperglycemia

Hyperglycemia Rationale: Long-term adverse effects that commonly occur with steroid therapy include hyperglycemia, osteoporosis, peptic ulcer disease, and increased risk for infection.

Meds for treatments: IBS-Constipation:

IBS-Constipation: a. Metamucil (bulk forming laxative that softens and enlarges fecal mass)) *take at meal times with a glass of water b. Linzess (newer) - teach to take daily 30 minutes before breakfast

Meds for treatment: IBS-Diarrhea:

IBS-Diarrhea: -Imodium, -Metamucil (to bulk up the poop) **take at meal times with a glass of water -alosetron (selective serotonin receptor antagonist - SLOWS motility) but CAREFUL - life-threatening SE's

Non surgical Treatment of a Hernia

If the patient is not a surgical candidate (often an older man with multiple health problems) the MD may prescribe a truss for an internal hernia, usually for men *A truss is a pad made with firm material. It is held in place over the hernia with a belt to help keep the abdominal contents from protruding into the hernial sac. If a truss is used it is applied only after the physician has reduced the hernia if it is not incarcerated. -they wear this every day TEACH pt. to assess skin daily, dust with powder lightly * Teach them NOT to strain or heavy lift or COUGH

Name that obstruction: - may have lower abdominal distention & perforation -minimal or no vomiting *obstipation or RIBBON LIKE STOOL -No major F&E imbalances *METABOLIC ACIDOSIS (not always present) -slow development, shape of stool may be altered -colonoscopy, rectal tube, maybe surgery -intermittent lower abdominal cramping

Large Bowel Obstruction

The patient is a 57-year-old male with a family history (sister, father) of colorectal cancer (CRC). His diet includes lots of red meat and fried foods. He was diagnosed with ulcerative colitis 3 years ago and treated for prostate cancer 2 years ago. What risk factors suggest a diagnosis of colorectal cancer for this patient?

Positive family history with first-degree relatives; dietary habits (red meat and fried foods); history of ulcerative colitis and prostate cancer.

Collaborative Problems/Potential Complications of a colostomy

Post op complication -Intraperitoneal infection -Complete large bowel obstruction -GI bleeding -Bowel perforation -Peritonitis, abscess, and sepsis

How are these findings in the 18 year old body builder significant?

These findings are extremely significant. Diverticulitis can perforate and develop a local abscess. This can progress to an intra abdominal perforation with peritonitis. If generalized peritonitis is present, profound guarding occurs; rebound tenderness is more widespread; and sepsis, hypotension or hypovolemic shock can occur! The patients occult stool test was positive for blood and excessive bleeding can result in severe hypotension and dehydration that result in shock (1186-1187). The nurse should monitor closely for signs of hypotension, hypo-perfusion, and shock.

This obstruction is associated with metabolic alkalosis and vomiting: ___________ This obstruction is associated metabolic acidosis and ribbon like stool:_____________

This obstruction is associated with metabolic alkalosis and vomiting: small bowel obstruction This obstruction is associated metabolic acidosis and ribbon like stool:Large bowel obstruction

A patient with IBS would present with pain in their _________ -What might they say usually relieves their pain -Is IBS more common in women or men?

a. left lower quadrant b. These patients symptoms are precipitated by eating, relieved by bowel movement c. IBS is more common in women *Most common digestive disorder seen in clinical practice

Pain BEFORE N/V may be

appendicitis

Risk Factors & Prevention for colorectal cancer

colorectal refers to the colon and rectum, which together makes up the large intestine, also known as the large bowel -Most are adenocarcinomas; most result from polyps **Risk factors: older than 50, genetics, family hx (esp first degree relatives), some viruses, crohns disease and ulcerative colitis smoking, obesity, inactivity, high fat diets, ethnicity(african americans less likely to survive) heavy alcohol consumption -Importance of screening procedures and diet! *Early screening is very important in preventing colorectal cancer ESP in patients whose first degree relatives have a history of colorectal cancer. Screening for them can begin as early as 20 **Teach patient s to decrease fat, refined carbs, and low fiber foods. Encourage baked or broiled foods esp those high in fiber and low in animal fat -encourage patients to eat vegetables including broccoli, cabbage, cauliflower, and sprouts because these foods help protect the intestinal mucosa from colorectal cancer

In persons 65 or older _________, ______, and ________ are the most common causes of obstruction

diverticulitis, tumors, and fecal impaction

When treating patients with obstructions lower in intestine think...

metabolic acidosis and ribbon like stools

When treating patients with obstructions high in small intestine think ...

metabolic alkalosis, vomiting

Manifestations of mechanical small intestine obstruction

mid-abd. pain/cramp, vomiting (foul, green, orange-brown), obstipation (not able to pass stool)

Manifestations of Mechanical colonic obstruction

milder intermittent colicky pain, lower abd. Distention & obstipation, ribbon-like stools

Abdominal pain increasing with cough or movement & relieved by bending right hip or knee suggests

perforation and peritonitis -Assess for Rebound tenderness

Question the patient about the passage of flatus, and record flatus and the character of bowel movements daily. Flatus or stool means that ______________ has returned.

peristalis