Concepts of care for patients with inflammatory intestinal conditions chapter 49

Concepts

The priority concepts in this chapter are - Infection - Inflammation The interrelated concepts in this chapter are - Nutrition - Elimination - Pain

Peritonitis analysis

The priority collaborative problems - Acute pain - Potential for fluid volume shift

Diverticular disease patho

Can occur in any part of the small or large intestine Diverticula without inflammation usually cause few problems Abscess, peritonitis can develop

Diverticulosis

outpouching of walls of intestine no clinical manifestations

Appendicitis patho

- Acute inflammation of the vermiform appendix - RLQ - Inflammation occurs when lumen of appendix is obstructed, leading to infection - Peritonitis - gangrene, sepsis, perforation can occur The image shows McBurney's point, which is located midway between the anterior iliac crest and the umbilicus in the right lower quadrant. This is the classic area for localized tenderness during the later stages of appendicitis.

Peritonitis planning and implementation

- Managing pain - Restoring fluid volume balance

Ulcerative colitis (in comparison to crohn's disease)

- Rectum and Colon - Etiology unknown - Peak incidence 15-25y;55-65y - Diarrhea 10-20 liquid bloody stools per day - Complications: - Hemorrhage - Nutritional deficiencies - Surgery infrequent

Crohn's disease (in comparison to ulcerative colitis)

- Small intestines - Etiology unknown - Peak incidence 15-40y - 5-6 soft, loose stools per day, steatorrhea - Complications: - Fistulas - Nutritional deficiencies - Surgery frequent

Ulcerative colitis incidence and prevalence

3 million have inflammatory bowel disease with about half experiencing ulcerative colitis Most diagnosed between 20 and 35 years of age

Crohn's disease patho

Chronic inflammatory disease of small intestine, colon, or both Inflammation that causes a thickened bowel wall Complications include hemorrhage, severe malabsorption, malnourishment, debilitation, cancer (although rare) Inflammation causing a thickened bowel wall Recurrent with remissions and exasterbation

Appendicitis

Clinical Manifestations - Abdominal pain - RLQ - Muscle rigidity - Guarding and rebound Diagnostic Studies - WBC - CT scan Complications - Abscess - Perforation - Peritonitis Collaborative Care/Nursing Interventions - NPO - IVF/IV antibiotics - Surgery ASAP

Management of diverticulosis and diverticulitis

Collaborative Care - Nursing Interventions - Drug Therapy •Metronidazole •Ciprofloxacin •Mild analgesics •Anticholinergics - Nutrition Therapy - Surgical •Resection with or without colostomy - Teaching •High fiber diet •Fluids •Avoid alcohol •S/S of diverticulits •Avoid laxitives •Care of colostomy

Peritonitis etiology

Common bacteria Chemical - leakage of bile, pancreatic enzymes, gastric acid

Comparison of Crohn's and Ulcerative Colitis

Crohn's Disease - Small intestines - Etiology unknown - Peak incidence 15-40y - 5-6 soft, loose stools per day, steatorrhea - Complications: - Fistulas - Nutritional deficiencies - Surgery frequent Ulcerative Colitis - Rectum and Colon - Etiology unknown - Peak incidence 15-25y;55-65y - Diarrhea 10-20 liquid bloody stools per day - Complications: - Hemorrhage - Nutritional deficiencies - Surgery infrequent

Diverticulosis/diverticulitis

Etiology and Pathophysiology - Diverticulosis- outpouching of walls of intestine - Diverticulitis - inflammation of diverticulum Clinical Manifestations - Diverticulosis - no clinical manifestations - Diverticulitis - LLQ abd pain - fever Complications - Perforation resulting in peritonitis - Hemorrhage - Obstruction Diagnostic Studies - WBC - Stool for OB - Sigmoidoscopy

Ulcerative colitis evaluation

Experience no diarrhea or a decrease in diarrheal episodes Verbalize decreased pain Have absence of lower GI bleeding Self-manage the ileostomy or ileo-anal pouch (temporary or permanent)

Ulcerative colitis etiology and genetic risk

Genetic, immunologic, environmental factors Often found in families and twins Cellular changes can increase colon cancer risk

Ulcerative colitis assessment

History - Nutrition and elimination history - Previos and curren therapy - Usual elimination patters - Stool contain blood, mucous, etc. - Tenesmes - urge to defecate Physical Assessment/Signs & Symptoms - May have low-grade fever - Usually finding are nonspecific Psychosocial Assessment - Anxiety Laboratory assessment - Hematocrit and hemoglobin (could be blood in stool, would be low) - Increased WBC, C-reactive protein, ESR - Low sodium, potassium, chloride (may be low due to diarrhea) - Hypoalbuminemia (lost proteins) Other diagnostic assessment - MRE - Upper endoscopy - Colonoscopy

Peritonitis assessment

History - Pain, type, and location - Fever Physical Assessment/Signs & Symptoms - Movement may be guarded - Abdominal pain, tenderness, and distention (feels like a board) - May have knees bent (decreases stretching of muscles) Psychosocial Assessment Laboratory assessment - WBC - Blood cultures - BUN, creatinine - Hemoglobin, hematocrit - ABG, oxygen saturation Imaging assessment - Abdominal x-rays or ultrasound

Care coordination and transition management (ulcerative colitis)

Home care management - salicylates, good for mild to moderate UC - 5 ASA's - Prednisone for acute flareups Self-management education - take a folic acid supplement (sulfa can affect absorption) (report N/V/D) Health care resources - controlling signs and symptoms - teach patient about the drugs

Care coordination and transition management (peritonitis)

Home care management Self-management education Health care resources

Care coordination and transition management of crohn's disease

Home care management Self-management education Health care resources

Appendicitis etiology and pathophysiology

Lumen of appendix obstructed - leading to infection

Ulcerative colitis planning and implementation

Managing diarrhea Managing pain Preventing or monitoring for lower GI bleeding - Increase fruits and vegetables - Keep and elimination diarrhea - Get plenty of rest

Gastroenteritis health promotion and disease prevention

Norovirus often occurs where large groups of people are in close proximity (cruise ships, nursing homes, college dorms, prisons) Handwashing** Do not share utensils and dishes Sanitize surfaces Proper food and beverage preparation Contact HCP is symptoms last longer than 3 days

Peritonitis (Infection Concept Exemplar)

Pathophysiology Overview - Life-threatening, acute inflammation and infection of visceral/parietal peritoneum and endothelial lining of abdominal cavity - Often caused by contamination of the peritoneal cavity by bacteria or chemicals

Diverticula (Diverticulosis)

Pictured above are several abnormal outpouchings, or herniations, that occur in the wall of the intestine, which are diverticula. These can occur anywhere in the small or large intestine but are found most often in the sigmoid, as shown in the figure. Diverticulitis is the inflammation of a diverticulum that occurs when undigested food or bacteria become trapped in the diverticulum. - outpouching of walls of intestine - food can get struck in these pouches

Ulcerative colitis analysis

Priority collaborative problems - Diarrhea - Acute or persistent pain - Potential for lower GI bleeding

Gastroenteritis interprofessional collaborative care

Recognize Cues: Assessment - Ask about recent travel, eating at restaurants or elsewhere - Nausea en vomiting - Fever - Abdominal cramping pain - Headache - Malaise - Dehydration - Dry mucous membranes - Oliguria - Positive result of stool culture Take Actions: Interventions - Encourage fluid replacement and oral rehydration therapy (ORAL IS BEST) (you can make your own with sugar and water) - Antibiotics may be needed - Avoid drugs that slow or reduce gastric motility - Protect the skin (stool is acidic, may need a wash cloth instead of TP)

Diverticular disease

Recognize Cues: Assessment - May have no symptoms - May have abdominal pain, fever, tachycardia, nausea, vomiting - Abdominal distention, tenderness Take Actions: Interventions - Nonsurgical management - Surgical management

Appendicitis interprofessional collaborative care

Recognize Cues: Assessment - RLQ abdominal pain, nausea, vomiting - Moderate WBC elevation - Ultrasound may show enlarged appendix Take Actions: Interventions - Nonsurgical management - Keep NPO - Surgical management

Crohn's disease interprofessional care

Recognize Cues: Assessment - Unintentional weight loss, stool characteristics, fever, abdominal pain - Assess for distention, masses, visible peristalsis - Anemia is common Take Actions: Interventions - Nonsurgical management - Surgical management

Peritonitis incidence and prevalence

Significant post-operative complications with 50% mortality rate

Peritonitis evaluation

Verbalizes relief or control of pain Experiences fluid and electrolyte balance

Gastroenteritis

Very common health problem Diarrhea and vomiting Self-limiting to ~ 3 days Can require medical attention or hospitalization for older adults or patients who are immunosuppressed Norovirus leading cause of food borne illness causing gastroenteritis

Ulcerative colitis (Inflammation concept exemplar)

Widespread chronic inflammation of the rectum and rectosigmoid colon Can extend into entire colon Has periodic remissions and exacerbations Stool contains blood and mucus Often confused with Crohn disease

Diverticulitis

inflammation of diverticulum LLQ abd pain - fever