Ch 49: Concepts of Care for Patients with Inflammatory Intestinal Disorders
Ulcerative Colitis: Analyze Cues and Prioritize Hypotheses: Analysis
The priority collaborative problems for patients with UC include: Diarrhea Acute or persistent pain Potential for lower GI bleeding Worry about skin breakdown - acid constantly on skin
Peritonitis: Analyze Cues & Prioritize Hypotheses: Analysis
The priority collaborative problems for patients with peritonitis include: Acute pain - big one Potential for fluid volume shift - shift from EC into peritoneal worry about hypotension
Diverticulosis and Diverticulitis diagnostic studies
CBC- WBC - elevated Stool for OB - see if bleeding is going on O/s or sigmoidoscopy - for better pictures
Diverticular Disease Pathophysiology review
Can occur in any part of the small or large intestine - most commonly in colon Diverticula without inflammation usually cause few problems\ Abscess, peritonitis can develop
Normal WBC
4,000-10,000
Crohn's Disease Pathophysiology Overview
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)
Ulcerative Colitis: Physical Assessment/Signs and Symptoms
Bloody diarrhea- frequent stools containing blood and mucus - 10 to 20 stools a day Weight loss Abdominal pain and cramping Low grade fever and fatigue Usually finding are nonspecific Psychosocial assessment Anxiety - stresses pt out to go to bathroom often
Appendicitis clinical manifestations
Abdominal pain - RLQ Muscle rigidity Guarding and rebounding N and V, anorexia
Peritonitis: Recognize Cues: Imaging Assessment
Abdominal x-rays or ultrasound - shows inflammation of peritoneum
Appendicitis Complications
Abscess Perforation Peritonitis
Ulcerative Colitis nutrition therapy
Acute flare up pt NPO
Appendicitis Pathophysiology overview
Acute inflammation of the vermiform appendix RLQ Inflammation occurs when lumen of appendix is obstructed, leading to infection Peritonitis - gangrene, sepsis, perforation Gangrene of bowel, sepsis serious complication
Ulcerative Colitis Drug therapy
Aminosalicylates (5-ASA) - decrease inflammation of lining of intestine taken several times a day Pt teaching - meds work well takes 2-4 weeks for meds to work 1. Mesalamine 2. Sulfasalazine Corticosteroids - used for flare ups lots of inflammation and pain - helps get inflammation under control
Gastroenteritis: Recognize Cues: Assessment
Ask about recent travel, eating at restaurants, or elsewhere GI symptoms (upper and lower) - vomiting/diarrhea high risk FVD Fluid volume deficit Get cues on what is going on with pt Worry about hypotension and hypovolemia with elderly
Management: Diverticulosis and Diverticulitis
Diverticulosis - no AB, diet controlled Nursing interventions - diet/meds
Diverticulosis and Diverticulitis Etiology and Pathophysiology
Diverticulosis - outpouching of walls of intestine - worry about this do not want to be diverticulosis Diverticulitis - inflammation or infection of diverticulum
Peritonitis: Incidence and Prevalence
Educate pt to wear mask gloves when doing dialysis at home Significant post-operative complication with 50% mortality rate Occurs most commonly with appendicitis
Gastroenteritis: Take Actions: Interventions
Encourage fluid replacement and oral rehydration therapy - gatorade, pedialyte Antibiotics may be needed - bacteria food outbreak DO NOT GIVE PT ANTIDIARRHEAL MEDS B/C WANT MICROORGANISMS TO WORK THEIR WAY OUT OF GI TRACT*
Ulcerative Colitis: Etiology and Genetic Risk
Exact cause unknown; Genetic, immunologic, environmental factors Often found in families and twins Cellular changes can increase colon cancer risk
Ulcerative Colitis: Evaluation: Evaluate Outcomes
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) - teach back for pt
Peritonitis: Etiology
Fluid shifts from EC into peritoneal cavity - can cause hypovolemia Common bacteria - E. coli or strep Chemical - leakage of bile, pancreatic enzymes, gastric acid Most common cause of death from surgical infections with mortality rate of 20% - can be as high as 50% for mortality
Ulcerative Colitis Laboratory Assessment
Hematocrit and hemoglobin - decreased blood loss through bowels Increased WBC, C-reactive protein, ESR - general inflammation markers not specific to UC Low sodium, potassium, chloride - losing electrolytes through bowel movements Hypoalbuminemia
Patient teaching Diverticulosis and Diverticulitis
High fiber diet Fluids Avoid alcohol S/S of diverticulitis - left lower quad abd pain Avoid laxatives - irritation increase GI motility Care of colostomy - good teaching get ostomy nurse Avoid seeds in food
Care Coordination and Transition Management Crohn's Disease/Ulcerative Colitis
Home care management - ostomy nurse meets w/ family and pt Self-management education Health care resources
The priority concepts in this chapter are
Infection Inflammation
Diverticulitis clinical manifestations
LLQ, abdominal pain and fever N/V Worry about hemorrhage obstruction
Crohn's Disease Labs/Diagnostic tests
Low h/h, increased ESR - inflammation X-rays, MRE - MRE more comm diagnosed Biopsy
Ulcerative Colitis other diagnostic assessment
MRE - similar to MRI drinking oral solution then looking at contrast in stomach through photos Upper endoscopy - upper part GI tract Colonoscopy - rectum to large intestine
Ulcerative Colitis: Generate Solutions and Take Actions Planning and Implemenation
Managing diarrhea Managing pain Preventing or monitoring for lower GI bleeding - looking at bowels, H/H levels
Peritonitis: Generate Solutions and Take action: Planning and Implementation
Managing pain: pain meds Treatment of infection: antibiotics Restoring fluid volume balance: big abdomen - N/V NPO, IV fluids - help maintain FV balance In acute stage pt NPO
Diverticular Disease Recognize Cues: Assessment
May have no symptoms May have abdominal pain, fever, tachycardia, nausea, vomiting Abdominal distention, tenderness
Ulcerative Colitis
Mostly in large intestine Widespread chronic inflammation of the rectum and rectosigmoid colon Can extend into entire colon Has periodic remissions and exacerbations - may feel great then have diarrhea - comes and goes Often confused with Crohn Disease
Peritonitis: Recognize Cues: Physical Assessment/Signs and Symptoms
Movement may be guarded - hand across abdomen Rigid, board-like abdomen (cardinal sign) Abdominal pain, tenderness, and distention Generally not feeling well Psychosocial assessment Anxiety associated pt not sure what is happening
Diverticulosis clinical manifestations
No clinical manifestations Pts do not know they have this
Diverticular Disease Take Actions: Interventions
Nonsurgical management Surgical management
Crohn's Disease Take Actions: Interventions
Nonsurgical management - 5 ASAs meds Surgical management - fixing the fistulas
Appendicitis: Take Actions: Interventions
Nonsurgical mangament Keep NPO IV fluids/IV antibiotics - b/c of infectious part Pain meds - usually in a lot of pain Surgical management- ASAP pt goes right to OR once confirmed
Gastroenteritis: Health Promotion/Disease Prevention
Norovirus often occurs where large groups of people are in close proximity Handwashing - proper hand hygiene Sanitize surfaces - in restaurant or cruises Proper food and beverage preparation - Food contamination - E. coli Salmonella - antibiotic needed Do not leave food sitting out long - dairy products
The interrelated concepts in this chapter are
Nutrition Elimination Pain `
Ulcerative Colitis: Recognize Cues: History
Nutrition and elimination - normal bowel diet recall - b/c main symptom is diarrhea
Peritonitis: Recognize Cues: Assessment History
Pain, type, location - where is it? what it feels like Fever, N and V
Diverticulosis and Diverticulitis complications
Perforation resulting in peritonitis Hemorrhage Obstruction
Ulcerative Colitis Surgery
Post-op ileostomy - med treatment not effective IV meds for outpt Illeostomy - pt teaching - change bag want stoma red/moist - no purulent drainage most pts go home with visiting nurse Pt should know how to empty and change bag
Drug therapy Diverticulosis and Diverticulitis
Pt treat with antibiotics unless Diverticulosis Metronidazole Ciproflaxin Mild analgesics and Anticholinergics - help with Diverticulitis abdominal spams
Appendicitis: Recognize Cues: Assessment
RLQ abdominal pain, nausea, vomiting Moderate WBC elevation Ultrasound may show enlarged appendix
Ulcerative Colitis characteristics
Rectum and Colon - large intestine Etiology unknown Peak incidence 15-25y; 55-65y Diarrhea 10-20 liquid bloody stools per day Complications: Hemorrhage - b/c bloody stools Nutritional deficiencies - abs in intestine cannot be abs b/c abnorm Surgery infrequent Can end up with Ileostomy or colestomy if meds not work
Crohn's Disease characteristics
Small intestines Etiology unknown Peak incidence 15-40y 5-6 soft, loose stools per day, steatorrhea Complications: Fistulas - bowels/nature Nutritional deficiencies Surgery frequent - fix the fistulas Can end up with Ileostomy or colestomy if meds not work
Appendectomy
Small slit put scope in to remove appendix - usually pt does not stay in hospital for long time
Drug therapy Crohn's Disease/Ulcerative Colitis
Sulfasalazine (Azullfidine) Corticosteroids - only in acute flare ups Nutritional therapy same as UC - NPO during acute flare ups Surgery - for repair of fistulas
Diverticulosis and Diverticulitis Management (cont.)
Surgical Resection with or without colostomy Some cases may need surgery
McBurney's point
The classic area for localized tenderness during the later stages of appendicitis Where pt usually has pain, usually guarded by pt
Crohn's Disease Recognize Cues: Assessment
Unintentional weight loss - b/c of diarrhea Stool characteristics-frequent soft, loose stools, steatorrhea - rarely bloody - loose stools less than UC-greasy stools Fever, abdominal pain Assess for distention, masses, visible peristalsis Fistulas from bowel to other organs Anemia is common - loose stools
Peritonitis: Evaluate Outcomes: Evaluation
Verbalizes relief or control of pain - want pt to be comfortable monitor I/Os make sure balanced Experiences fluid and electrolyte balance
Ulcerative Colitis: Incidence and Prevalence
Very common 3 million have inflammatory bowel disease with about half experiencing ulcerative colitis Most diagnosed between 20 and 35 years of age
Gastroenteritis
Very common health problem Diarrhea and vomiting - stomach bug Can be due to viral or bacteria infection - viral more common Norovirus - large groups of people on cruises, nursing homes Self-limiting to ~ 3 days Can require medical attention or hospitalization for older adults or patients who are immunosuppressed
Peritonitis pathophysiology overview
Very serious 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 and chemicals Bacteria can be spread by appendicitis diverticulitis
Appendicitis Diagnostic studies
WBC - elevated CT scan - better image can see inflamed appendix
Peritonitis: Recognize Cues: Laboratory Assessment
WBC -elev Blood cultures - to see bact if it moved in bloodstream - rule out septicemia BUN, creatinine, Hemoglobin, hematocrit - not specific to peritonitis ABG, oxygen saturation
Diverticulosis and Diverticulitis Nutrition therapy
When pt having episode want pt to be NPO then eat high fiber diet lots of fluids 2-3L/day Foods to avoid: seeds/everything bagels, strawberries, raspberries, grapes, corn, popcorn, watermelon, nuts, kernels - anything that can dislodge and turn into infectious process
