mod 9 - GI

what is intestinal diversion?

(Bowel diversion surgery) allows stool to safely leave the body when the large intestine is removed or needs time to heal from disease or injury

what should the nurse be monitoring regarding fluid balance during preop of a pt undergoing colorectal surgery?

- SS of hypovolemia - hydration status, skin turgor, dry mucous mems, and concentrated urine

what is done during preop to maintain fluid volume balance for pts undergoing colorectal surgery?

- an orogastric tube may be inserted to drain accumulated fluids and prevent abdominal distention

what is given to treat diarrhea as a complication of intestinal diversion surgery and why?

- antidiarrheal agents - supplemental water, sodium, and potassium (to prevent hypovolemia and hypokalemia)

in preparation for a pt discharge following colorectal surgery, the nurse should educate the patient to notify their provider if they experience what symptoms that may indicate complications?

- bleeding - abd distention & rigidity - abrupt abd pain - diarrhea - fever - disruption of suture line

what is done in preop to prevent infection for pts undergoing colorectal surgery?

- bowel in cleansed with laxatives, enemas, or colonic irrigations the evening before and the morning of surgery - some surgeons also prescribe oral antibiotics the day before surgery or IV antibiotics immediately before the surgery to reduce intestinal bacteria

What are the signs and symptoms of bile reflux in patients undergoing gastrectomy?

- burning epigastric pain that may inc after meals - (vomiting usually does not provide relief of pain)

when should colostomy irrigation be performed and why?

- consistent with when the pt will do it after leaving the hospital - before social and business activities to avoid fear of fecal drainage

what are the two main concerns with geriatric patients following intestinal diversion surgery? and why?

- delayed healing, from dec blood flow to the wound caused by arteriosclerosis - skin care bc of skin changes that occur with aging

how often should the patient cleanse the peristomal skin to prevent skin excoriation around the stoma?

- each time the ostomy pouch is changed, which can vary from 5-10 days

how often is the pouch drained of fecal matter following intestinal diversion surgery?

- every 4-6 hrs - when pouch is 1/2 full - same time pt empties bladder

Colostomy irrigation is contraindicated for people with:

- extensive pelvic irradiation (carries risk of perforation) - receiving chemo - IBS - Crohn's ds - diverticulitis - peristomal hernias

later on following intestinal diversion surgery (after 6-8 weeks), what is avoided as dietary restrictions?

- foods high in fiber - gas producing foods like eggs and dried peas - hard-to-digest kernels, like dried fruits, nuts, celery, popcorn, corn, poppy seeds, coconut, etc. - enteric-coated medications - foods that may thicken stool like rice, pasta, mashed potatoes, and apple sauce - foods that act as deodorizers in the intestinal tract like spinach and parsley

symptoms of dumping syndrome can be broadly divided into:

- gastrointestinal --> nausea, cramping, abd pain, and diarrhea - vasomotor --> sweating, tachy, palpitations, flushing, and dizziness

what are the types of intestinal diversion?

- ileostomy - colostomy

In the preoperative period, the nurse caring for a patient undergoing colorectal surgery/intestinal diversion should monitor the patient for which signs and symptoms of intestinal obstruction/perforation?

- inc distention - loss of bowel sounds - pain - rigidity

intestinal diversion is indicated for what medical conditions?

- inflammatory bowel disease (Crohn's and ulcerative colitis) - diverticulitis - advanced colon cancer

why is urinary calculi a possible complication of intestinal diversion surgery?

- may occur in patients with ileostomies and they are attributed to dehydration - The use of the ileum in urinary intestinal diversion may result in excess bile salts binding calcium and causing increased absorption of oxalate, increasing the risk of oxalate calculi. In addition, excess conduit length, dehydration and urine stasis may put patients at an increased risk of stone formation.

what are possible complications following ostomy surgery (intestinal diversion)?

- peristomal skin irritation - diarrhea - stenosis of the stoma - urinary calculi - intestinal obstruction

what is included in the pharmacologic management of bile reflux?

- sucralfate (Carafate) - cholestyramine (Questran) (binds with bile acids in the GI tract and facilitates the elimination of bile acids in the stool

what should the nurse monitor the stoma for following intestinal diversion surgery?

- swelling - color - discharge (sm amt of oozing normal) - bleeding

What essential patient and family education should the nurse provide to the patients undergoing a colorectal surgery/intestinal diversion?

- why it is necessary for the pt to occupy the bathroom for 10+ mins certain times of the day - why certain equipment is needed

1) patients with inflammatory bowel disease are usually receiving which medications? 2) are these medications continued or discontinued during the surgical phase of a pt undergoing intestinal diversion?

1) corticosteroids 2) continued to prevent steroid-induced adrenal insufficiency

1) The nurse caring for a post-colostomy patient anticipates which medication to be prescribed to diminish intestinal motility, thereby thickening the stool and assisting in odor control? 2) what do these medications do?

1) oral diphenoxylate with atropine 2) diphenoxylate is an opioid and acts by slowing intestinal contractions; the atropine prevents drug abuse and overdose

in the early postop period of a pt who underwent intestinal diversion surgery, how much fluid may be lost from the stoma each day?

1000-2000 ml

If an abdominoperineal resection was done, how frequently should perineal irrigation of the wound or sitz baths be performed initially as part of wound care?

2-3 times per day

how long after a meal does late dumping (hypoglycemic) occur?

2-4 hours after meal

how long does it usually take for early dumping to occur after a meal?

45 mins after meal

A patient has received a diagnosis of gastric cancer and is awaiting a surgical date. During the preoperative period, the patient should adopt what dietary guidelines? A. Eat small, frequent meals with high calorie and vitamin content. B. Eat frequent meals with an equal balance of fat, carbohydrates, and protein. C. Eat frequent, low-fat meals with high protein content. D. Try to maintain the pre-diagnosis pattern of eating.

A. Eat small, frequent meals with high calorie and vitamin content. feedback: The nurse encourages the client to eat small, frequent portions of nonirritating foods to decrease gastric irritation. Food supplements should be high in calories, as well as vitamins A and C and iron, to enhance tissue repair.

When planning assessments, the nurse should be aware of what potential postoperative complication of a gastrostomy? A. Premature removal of the G tube B. Bowel perforation C. constipation D. development of peptic ulcer disease

A. Premature removal of the G tube

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has had not ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? A. Report signs and symptoms of obstruction to the health care provider. B. Contact the physician and obtain a swab of the stoma for culture. C. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. D. Encourage the client to mobilize in order to enhance motility.

A. Report signs and symptoms of obstruction to the health care provider. feedback: It is important to report nausea and abdominal distention, which may indicate intestinal obstruction. This requires prompt medical intervention. Referral to the WOC nurse is not an appropriate short-term response, since medical treatment is necessary. Physical mobility will not normally resolve an obstruction. There is no need to collect a culture from the stoma, because infection is unrelated to this problem.

Which of the following information should the nurse include in the teaching plan of a pt with ileostomy? A. empty the pouch when it is 1/2 full B. hold pressure on the skin barrier for 10-15 sec to secure the seal C. clean the peristomal skin four times a day D. expect firm fecal content

A. empty the pouch when it is 1/2 full

A client with a diagnosis of colon cancer is 2 days postoperative following bowel resection and anastomosis. The nurse has planned the client's care in the knowledge of potential complications. What assessment should the nurse prioritize? A. Assessment of hemoglobin, hematocrit, and red blood cell levels B. Frequent abdominal auscultation C. Close monitoring of temperature D. Palpation of peripheral pulses and leg girth

B. Frequent abdominal auscultation feedback: After bowel surgery, it is important to frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction. The resumption of bowel motility is a priority over each of the other listed assessments, even though each should be performed by the nurse. Obstruction can develop more quickly than infection in most cases.

A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. A high-calorie, high-residue diet B. High intake of strained fruits and vegetables C. A minimum of 30 g of soluble fiber daily D. Increased intake of free water and clear juices

B. High intake of strained fruits and vegetables feedback: A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are given. These foods are important sources of vitamins A and C. Adequate fluid intake is important, but it does not need to be particularly high. High fiber intake would lead to complications.

Pt with ileostomy. Stoma is bright red & there are scant amounts of blood on the stoma. What is the nurse's best action? A. contact care provider to have the HgB and Hct measured B. document these expected assessment findings C. apply barrier ointment to the stoma as prescribed D. cleanse the stoma with alcohol or chlorohexidine

B. document these expected assessment findings

The pt has had not ostomy output for 12hrs. Pt reports worsening nausea. What is the nurse's priority action? A. facilitate referral to the wound-ostomy-continence (WOC) nurse B. report S&S of obstruction to the health care provider C. encourage the client to mobilize in order to enhance motility D. contact the physician and obtain a swab of the stoma for culture

B. report S&S of obstruction to the health care provider

A client is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that he may experience which of the following adverse effects associated with this procedure? A)Persistent feelings of hunger and thirst B)Constipation or bowel incontinence C)Diarrhea and feelings of fullness D)Gastric reflux and belching

C)Diarrhea and feelings of fullness feedback: Following a Billroth I, the client may have problems with feelings of fullness, dumping syndrome, and diarrhea. Hunger and thirst, constipation, and gastric reflux are not adverse effects associated with this procedure.

What should the nurse do on a daily basis to prevent skin breakdown in pt with a gastrostomy tube? A. Verify tube placement B. Loop adhesive tape around the tube and connect it securely to the abdomen. C. Gently rotate the tube D. Change the wet-to-dry dressing

C. Gently rotate the tube

Pt is scheduled for an ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. minimum of 30g of soluble fiber daily B. inc intake of free water and clear juices C. high intake of strained fruits and vegetables D. a high-cal, high-residue diet

C. high intake of strained fruits and vegetables

Which of the following foods should the nurse include in the teaching of colostomy pt about appropriate foods? A. eggs B. dried peas C. pasta D. dried fruits

C. pasta

Family of a comatose pt asks why the physician recommended removal of NG tube and the insertion of a gastrostomy tube? A. it eliminates the risk for infection B. feeds can be infused at a faster rate C. regurgitation and aspiration are less likely D. it allows caregivers to provide personal hygiene more easily

C. regurgitation and aspiration are less likely

A patient has experienced symptoms of dumping syndrome following bariatric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A) Irritation of the phrenic nerve due to diaphragmatic pressure B) Chronic malabsorption of iron and vitamins A and C C) Reflux of bile into the distal esophagus D) A sudden release of peptides

D) A sudden release of peptides feedback: The rapid bolus of hypertonic food from the stomach to the small intestines draws extracellular fluid into the lumen of the intestines to dilute the high concentrations of electrolytes and sugars, which results in intestinal dilation, increased intestinal transit, hyperglycemia, and the rapid onset of GI and vasomotor symptoms, which characterizes dumping syndrome. It is not a result of phrenic nerve irritation, malabsorption, or bile reflux.

why should the nurse closely monitor serum electrolyte levels during preop of a pt who has an orogastric tube before surgery?

The GIT loss associated with gastric drainage might result in hypokalemia and hyponatremia

what is the Billroth 1 operation?

a type of reconstruction after a partial gastrectomy where the stomach is connected to the duodenum

when is the final size of the stoma selected following intestinal diversion surgery?

after 3 months, after the pt's wt has stabilized and the stoma shrinks to a stable shape

why is malabsorption of vitamins and minerals a concern following gastric surgery?

after a total gastrectomy, there will be a lack of intrinsic factor (normally secreted by parietal cells in the stomach & binds to V-B12 to be absorbed into the ileum) - deficiency in V-B12 metabolism can cause a dec in production of RBCs, which may cause pernicious anemia

₋ Why does the post-gastrectomy patient need to have regular injections of Vit B12?

after a total gastrectomy, there will be a lack of intrinsic factor (normally secreted by parietal cells in the stomach & binds to V-B12 to be absorbed into the ileum) - deficiency in V-B12 metabolism can cause a dec in production of RBCs, which may cause pernicious anemia

stenosis of the stoma, a possible complication of intestinal diversion surgery, is caused by what?

circular scar tissue that forms at the stoma site

how is the GI tract reconstructed after a total gastrectomy

connecting the jejunum to the end of the esophagus

what does drainage from an ileostomy look like and why?

continuous liquid fluid from the small intestine bc the stoma does not have a controlling sphincter

if skin excoriation around the stoma occurs, how do we treat it?

dust nystatin powder (Mycostatin) lightly on the peristomal skin

what are the two types of dumping syndrome?

early (osmotic) and late (hypoglycemic)

if the fecal discharge is too watery after intestinal diversion surgery, what foods are restricted?

fibrous foods like whole-grained cereals, fresh fruit skins, beans, corns, and nuts

What are the preoperative dietary considerations for patients undergoing colorectal surgery/intestinal diversion?

for several days before surgery, the diet should be high in calories, protein, and carbohydrates and low in residue (fiber) - to provide adequate nutrition and minimize cramping by decreasing excessive peristalsis

what do we monitor for when providing wound care during postop after colorectal surgery?

hemorrhage and infection

how might a patient develop gastritis or esophagitis following a gastric surgery?

if there is prolonged exposure of bile acid from the duodenum, which results in irritation and damage to the gastric mucosa

When is the fecal drainage expected to begin after ileostomy versus colostomy?

ileostomy = 24-48 hrs after surgery colostomy = 3-6 days after surgery

what occurs during dumping syndrome?

in both types, a large volume of gastric content is delivered to the duodenum or jejunum resulting in symptoms of dumping

When caring for a post- colorectal surgery/intestinal diversion patient, the nurse should monitor the patient closely for which signs and symptoms of bowel obstruction?

inc distention, loss of bowel sounds, and pain or rigidity

When caring for a post- colorectal surgery/intestinal diversion patient, the nurse should monitor the patient closely for which signs and symptoms of intra-abdominal infection?

inc temperature, pulse, and respirations, elevated white blood cell counts

what is diverticulitis?

inflammation of small pouches called diverticula that develop along the walls of the intestines

what are the manifestations of hypoglycemia?

irritability, anxiety, shakiness, weakness, fatigue, diaphoresis, palpitations, and hunger

for the first 6-8 weeks following intestinal diversion surgery, what diet is followed?

low-residue (low fiber) diet - strained (clear without pulp) fruits and veggies are ingested for sources of Vitamin A and C

why should foods that are high in fiber be avoided after intestinal diversion surgery?

may lead to diarrhea, constipation, or obstruction

Can the patient with ileostomy establish regular bowel habits?

no bc the contents of the ileum are fluid and are discharged continuously

why does early dumping occur?

passage of a large volume of osmotic material into the small bowel, causing an incursion of fluid from the intravascular space

what is the most common complication following the placement of an ostomy?

peristomal skin irritation (which results from leakage of the drainage)

how might a patient develop a gastric outlet obstruction following gastric surgery?

possibly by narrowing (stenosis) or scar tissue (stricture) formation at the surgical site

why does hypoglycemia occur with late dumping syndrome?

rapid delivery of sugars/carbs into the duodenum result in rising blood sugar levels which then cause an extreme serum insulin response with subsequent rebound hypoglycemia

When caring for a post- colorectal surgery/intestinal diversion patient, the nurse should monitor the patient closely for which signs and symptoms of hemorrhage?

rectal bleeding

abdominoperineal resection

removal of the tumor and a portion of the sigmoid and all the rectum and anal sphincter - perineal drain is inserted

segmental resection

removal of the tumor and portions of the bowel on either side of the growth, as well as the blood vessels and lymphatic nodes

what is the Billroth 2 operation?

removing approximately 75% of the stomach

if the fecal discharge is excessively dry after intestinal diversion surgery, what is implemented?

salt intake is increased

what diet is implemented 24-48 hours before a patient undergoes intestinal diversion?

small frequent feeding of low-residue (low-fiber) clear liquid diet

with the loss of fluid from the stoma after an intestinal diversion surgery, what electrolytes may be depleted?

sodium and potassium

what is a total gastrectomy?

surgery in which the entire stomach is removed along with duodenum, the lower portion of the esophagus, supporting mesentery, and lymph nodes

bile reflux is a possible complication for what types of gastric surgeries?

surgery that involves removal of the pylorus sphincter, that prevents reflex of duodenal contents back into the stomach

what is an ileostomy?

surgical creation of an opening into the ileum or small intestine.

what is a colostomy?

surgical opening into the colon by means of a stoma

In the preoperative period, the nurse caring for a patient undergoing colorectal surgery/intestinal diversion should monitor the patient for which signs and symptoms of hypovolemia?

tachycardia, hypotension, decreased pulse volume, weakness, sweating

what is the purpose of irrigating a colostomy?

to empty the colon of gas, mucus, and feces bc the stoma does not have voluntary muscular control and may empty at irregular intervals

in the early postop period of a pt who underwent intestinal diversion surgery, why might an NG tube be placed?

to prevent buildup of gastric contents while the intestines are not functioning

why should enteric-coated meds be avoided after intestinal diversion surgery?

to reduce the risk of stomal blockage caused by the coating

what is the most common purpose of colorectal surgeries

treatment of colorectal cancer

what is an orogastric tube?

tube inserted through the mouth into the stomach to facilitate gastric suctioning and/or decompression

postoperative bleeding as a complication of gastric surgery can manifest as what symptoms?

vomiting large amts of bright red blood (which may cause hemorrhagic shock)