Med-surg Ch. 48 (acute inflammatory intestinal disorders):

Signs indicating peritonitis is subsiding:

-Decreased temp -Decreased pulse -Softening of the abdomen -Return of BS -Passing of flatus & bowel movements

Two common complications of surgical management in the pt. with peritonitis:

-Evisceration (sudden occurrence of serosanguineous drainage strongly suggest this) -Abscess formation

Surgical treatment of peritonitis is directed towards:

-Excision (Ex: appendix) -Resection with or without anastomosis (Ex: intestine) -Repair (Ex: perforation) -Drainage (Ex: Abscess)

Course of ulcerative colitis:

-Exacerbations, remissions

Diverticulosis:

-Multiple diverticula are present *without* inflammation or symptoms

Complications of appendicitis:

*-Perforation* of the appendix which leads to the following: -Peritonitis -Abscess formation -Portal pylephlebitis (septic thrombosis of the portal vein caused by vegetative emboli that arise from septic intestines)

Pathology of ulcerative colitis:

*Early* -Mucosal ulceration -Minute, mucosal ulcerations

Pathology of crohn's disease:

*Early* -transmural thickening *Late* -deep, penetrating granulomas

Nursing interventions for peritonitis:

*Monitor for* -Abdominal tenderness -Fever -Vomiting -Abdominal rigidity -Tachycardia -Assess for bowel sounds -Constant nasogastric suction -Correct dehydration as prescribed -Prepare for surgery, if mechanical ileus is established

Because pts. with IBD have decreased bone mineral density they are at an increased risk for what?

-Osteoporotic fractures

When the colon is surgically removed for a pt. who has ulcerative colitis they are considered:

-Cured -Extraintestinal manifestations subside -Disease process is otherwise limited to the colon

If peritonitis is suspected after surgery for appendicitis what is done?

-A drain is left in place at the area of the incision -Pt. may be kept in the hospital for several days -Pt. is carefully monitored for s/sx of intestinal obstruction or secondary hemorrhage

What would you expect to see with a sigmoidoscopy if the diagnosis was ulcerative colitis?

-Abnormal inflamed mucosa

Manifestations of diverticulitis:

-Acute onset of mild to severe pain in the *LLQ* accompanied by nausea, vomiting, fever, chills, & leukocytosis -Constipation due to repeated inflammation *If perforation has occurred:* -Abdominal pain -Rigid board-like abdomen -Absent bowel sounds -Signs of shock *If an abscess occurs* -Tenderness -Palpable mass -Fever -Leukocytosis

Nursing interventions for pelvic abscess:

-Administer antibiotics as prescribed -Evaluate the pt. for anorexia, chills, fever, & diaphoresis -Observe for diarrhea, which may indicate pelvic abscess -Prepare the pt. for rectal exam -Prepare the pt. for surgical drainage procedure

Nursing interventions to relieve pain in the pt. with IBD:

-Administer anticholinergics 30 mins before a meal as prescribed to decrease intestinal motility

Before the pt. undergoes surgery for appendicitis the RN:

-Administers IV fluids to replace fluid loss and promote renal function -Administers antibiotics are prescribed -Insert an NG tube if there is evidence/likelihood of paralytic ileus *Do not administer an enema (can cause perforation)

Foods that cause odors in the intestinal tract:

-Asparagus -Cabbage -Onions -Fish

Nursing interventions for subphrenic abscess (under the diaphragm):

-Assess the pt. for chills, fever, & diaphoresis -Prepare the pt. for X-ray -Prepare the pt. for surgical drainage

Nursing management for the pt. with peritonitis:

-BP is monitored by arterial line (art line) if shock is present (ART line blood can be drawn; no fluids in) -Central venous pressure or pulmonary artery wedge pressure and urine output are monitored freq. -Assessment of GI function, fluid/electrolyte status -Administer analgesics *Position the pt. on one side with knees flexed to decrease tension on abdominal organs* -NGT may be necessary -Increase fluid and food intake gradually and reduces parenteral fluids as prescribed -Monitor any drains

Manifestations of diverticulosis:

-Bowel irregularity with intervals of diarrhea, nausea, anorexia, bloating/abdominal distention, & weakness

Treatment for abscess formation without peritonitis, hemorrhage or obstruction in the pt. with diverticulitis:

-CT guided percutaneous drainage may be performed -IV antibiotics -After the abscess is drained & inflammation subsides (approx 6 weeks) surgery is recommended to prevent repeat episodes

Diagnostic test for diverticulitis:

-CT scan -Abdominal x-ray may detect free air under the diaphragm if perforation occurred -CBC which would show increased WBC & increased erythrocyte sedimentation rate (ERS) *Colonoscopy is contraindicated b/c the risk for perforation in the presence of local infection may result in sepsis *Barium enema is contraindicated

Treatment of a mild case of diverticulitis:

-Can be treated on an outpatient basis w/diet & medication -Rest -Analgesic medications -Antispasmodic agents -Clear liquid diet until inflammation subsides then a high-fiber, low-fat diet is recommended (helps increase stool volume, decrease colonic transit time, and reduce intraluminal pressure) -Bulk-forming laxative are prescribed -Antibiotics for 7-10 days

Therapeutic management of ulcerative colitis:

-Corticosteroids, aminosalicylates -Bulk hydrophilic agents -Antibiotics -Proctocolectomy with ileostomy -Rectum can be preserved in only a few patients "cured" by colectomy

Inflammatory bowel disease (IBD):

-Chronic disorder that results in inflammation and/or ulceration of the bowel line (Crohn's or ulcerative colitis) -NSAIDS exacerbate this

Diagnostic test for diverticulosis:

-Colonoscopy

Nursing diagnoses for diverticulitis:

-Constipation r/t narrowing of the colon from thickened muscular segments and strictures -Acute pain r/t inflammation and infection

Therapeutic management of regional enteritis:

-Corticosteroids, aminosalicylates -Antibiotics -Parenteral nutrition -Partial or complete colectomy with ileostomy or anastomosis

Manifestations of ulcerative colitis:

-Diarrhea -Passage of mucus and pus *-LLQ pain* -Intermittent tenesmus (cramping when going to the restroom) *-Rectal bleeding* -Anorexia -Weight loss -Cramping *-Passage of 10-20 liquid stools/day* -Pallor -Fatigue -Rare to mild perianal involvement -Fistulas are rare -Rectal involvement is almost 100% -Diarrhea is more severe than crohn's -Abdominal mass is rare

Nursing diagnoses for IBD:

-Diarrhea r/t the inflammatory process -Acute pain r/t increased peristalsis and GI inflammation -Deficient fluid volume r/t anorexia, nausea, and diarrhea -Imbalanced nutrition: less than body requirements r/t dietary restrictions, nausea, & malabsorption -Activity intolerance r/t generalized weakness -Ineffective coping r/t repeated episodes of diarrhea -Anxiety r/t impending surgery -Risk for impaired skin integrity r/t malnutrition and diarrhea -Risk for ineffective self-health management r/t insufficient knowledge concerning the process and management of disease

What would you expect to see with a barium study if the diagnosis was ulcerative colitis?

-Diffuse involvement -No narrowing of colon -No mucosal edema -Stenosis is rare -Shortening of the colon

Manifestations of peritonitis:

-Diffuse pain that becomes constant, localized, and more intense over the site. Aggravated by movement -Distended muscles becomes rigid -Rebound tenderness -Paralytic ileus -Anorexia -Nausea -Vomiting -Decreased peristalsis -Temp of 100-101 degrees -Increased pulse rate -With progression pt. may become hypotensive *Pts. with advanced neuropathy and pts. with cirrhosis who have ascites may not experience pain during an acute bacterial infectious process

What would you expect to see with a colonoscopy is the diagnosis was crohn's disease?

-Distinct ulcerations separated by relatively normal mucosa in ascending colon

Marking the stoma site preoperatively:

-Done by the surgeon of the WOC -Placed in the RLQ 2 inches below the waste, away from any previous scars, bony prominences, skin folds, or fistulas -Stoma site must be visible to the pt.

Signs/symptoms of fluid volume deficit:

-Dry skin & mucus membranes -Decreased skin turgor -Oliguria -Fatigue -Decreased temp -Increased Hct -Elevated urine specific gravity -Hypotension

Postoperative care for the pt. who had an ileostomy:

-Early ambulation -Administer prescribed analgesics as prescribed -Observe the stoma for color and size: it should be pink to bright red and shiny -Monitor for fecal drainage which should begin 24-48 hours after surgery; drainage should be continuous liquid; the drainage is collected, measured and discarded when the pouch becomes full -I&O monitoring (including fecal discharge); there may be an additional 1,000-2,000 mL of fluid lost each day (this causes loss of sodium and potassium) -IV fluids are administered for 4-5 days to replace the fluid loss -NG suction may be needed, with the tube requiring freq. irrigation as prescribed (purpose is to prevent the buildup of gastric contents while the intestines are not functioning); once the tube is removed clear liquids are offered and the diet is gradually increased -Nausea and abdominal distention need to be reported immediately (could indicate intestinal obstruction) -If rectal packing was used, it is removed by the end of the first week. RN may administer an analgesic 1 hour before the removal. After the packing is removed, the perineum is irrigated 2-3 times daily until fully healed

Collaborative problems/potential complications for IBD:

-Electrolyte imbalance -Cardiac dysrhythmias r/t electrolyte imbalances -GI bleeding with fluid volume loss -Perforation of the bowel

Manifestations of secondary abscesses after surgery for appendicitis:

-Elevation of temp, pulse rate, and WBC's

Symptoms of toxic megacolon:

-Fever -Abdominal pain & distention -Vomiting -Fatigue *If the pt.. does not respond within 24-72 hours to medical management with nasogastric suction, IV fluids with electrolytes, corticosteroids, and antibiotics, surgery is required.

Medical management of peritonitis:

-Fluid, colloid, & electrolyte replacement -Several liters of isotonic solution (b/c of hypovolemia) -Analgesic medications -Antiemetic agents -NGT with suction to relieve abdominal distention -O2 therapy by nasal cannula or mask, intubation and vent assistance may be needed -Antibiotic therapy early in the treatment *If caused by peritoneal dialysis, prompt antibiotic treatment is crucial. If the peritonitis does not respond to the therapy in 5 days, the catheter should be removed*

What would you expect to see with a colonoscopy if the diagnosis was ulcerative colitis?

-Friable mucosa with pseudopolyps or ulcers in the descending colon

Elemental feeding:

-High in protein -Low in fat and residue -Digested primarily by the jejunum and do not stimulate intestinal secretions -Allow the bowel to continue to rest

Treatment of an acute care of diverticulitis:

-Hospitalization is required -NPO status -Administering IV fluids -NGT if vomiting or distention is present (to rest the bowel) -Broad-spectrum antibiotics for 7-10 days -Analgesic agent may be prescribed -If surgery is needed, pain management will include parenteral opioids -Oral intake is increased as symptoms subside -Low-fiber diet may be needed until signs of infection decrease *surgical intervention is needed if there is perforation, peritonitis, hemorrhage or obstruction present

Small bowel resection:

-Indicated for crohn's disease -Diseased segments of the small intestines are resected, and the remaining portions of the intestines are anastomosed -Surgical removal of up to 50% of the small bowel can usually be tolerated

Strictureplasty:

-Indicated for crohn's disease -Performed for strictures of the small intestine -Laparoscope-guided -Blocked or narrowed sections of the intestines are widened leaving the intestines intact

Even with surgical treatment in Crohn's disease recurrence of inflammation and disease is:

-Inevitable

Diverticulitis:

-Infection & inflammation in a diverticulum often caused by retained food and bacteria

Manifestations of regional enteritis (Crohn's disease):

-Insidious *Prominent RLQ abdominal pain unrelieved by defecation* -Diarrhea unrelieved by defecation -Abdominal tenderness and spasm *-Crampy pain after meals* -Weight loss -Malnutrition & secondary anemia -Common perianal involvement -Common fistulas -Rectal involvement is about 20% -Diarrhea is less severe compared to ulcerative colitis -Abdominal mass is common

*Complications of crohn's disease:

-Intestinal obstruction or stricture formation -Perianal disease -Fluid/electrolyte imbalances -Malnutrition from malabsorption -Most common type of small bowel fistula is the enterocutaneous fistula (abnormal opening between the small bowel and the skin) -Abscesses as a result of an internal fistula -Risk for colon cancer

If constipation occurs with appendicitis the RN should *NOT* give a laxative because:

-It can cause perforation of the inflamed appendix

What should the RN tell the pt. during discharge instructions after surgery for appendicitis:

-Make an appointment to have the surgeon remove any sutures and inspect the wound between the *5th & 7th* day after surgery -No heavy lifting -Normal activity can resume within 2-4 weeks

Preoperative education for the pt. undergoing an ileostomy includes:

-Management of drainage from the stoma -Nature of drainage from the stoma -The need for NG intubation, parenteral fluids, and possibly perineal packing

What would you expect to see with a sigmoidoscopy if the diagnosis was crohn's disease?

-May be unremarkable unless accompanied by perianal fistulas

Intestinal transplant:

-Newer surgery for severe crohn's disease -Available for children to young & middle aged adults who have lost intestinal function from disease

Nutritional therapy for IBD:

-Oral fluids -Low-residue, high-protein, high calorie diet -Supplemental vitamin therapy & iron replacement -Avoid foods that exacerbate diarrhea -Parenteral nutrition may be needed *May need to avoid milk products *Cold food and smoking should be avoided b/c they increase intestinal motility

Signs of a ruptured appendix:

-Pain that is more diffuse -Abdominal distention (b/c of paralytic ileus) -Worsening of the pts. condition *Life threatening*

After surgery for a pt. who had surgery for appendicitis the RN:

-Places the pt. in high Fowler's -Administer morphine sulfate as prescribed -When tolerated, oral fluids are administered -Any pt. who was dehydrated before surgery will need IV fluids after -When normal bowel sounds are present food may be provided as desired

Managing skin and stoma care:

-Pouch must be worn at all times for pts. with an ileostomy (b/c discharge is continuous/liquid) -Stoma should be checked 3 weeks after surgery, when the edema has subsided -The final size and type of the appliance is selected in 3 months, after the pts. weight has stabilized and the stoma shrinks to a stable shape -Usually the ileostomy stoma is about 1 inch long -Skin excoriation around the stoma can be a persistent issue -If irritation and yeast growth occur, nystatin powder (mycostatin) is lightly dusted on the peristomal skin and a pouch with skin barrier is applied over the affected area

Course of Crohn's disease:

-Prolonged, variable

Nursing interventions for the pt. with IBD receiving parenteral nutrition:

-RN maintains I&Os -Daily weights *the pt. should gain 1.1lb daily* -Blood glucose levels every 6 hours -Once parenteral nutrition is stopped the pt. is advanced to elemental feedings *once oral foods are tolerated* -Small freq. low-residue feedings are given to avoid over distending the stomach and stimulating peristalsis -The pt. must restrict activity to conserve energy, reduce peristalsis and reduce caloric requirements

Nursing interventions to maintain normal elimination patterns in the pt. with diverticulitis:

-RN recommends a fluid intake of 2 L/day (at least 10 glasses of water a day) -RN suggest foods that are soft but have increased fibers, such as prepared cereals or soft cooked veggies -RN encourages an individualized exercise program to increase abdominal muscle tone -RN encourages daily intake of bulk laxatives (psyllium); oil retention enemas may be prescribed or laxatives -RN teaches the client to avoid nuts, popcorn and anything with seeds -Opioid Analgesics -Antispasmodics

Ulcerative colitis occurs in what location:

-Rectum, descending colon (causes LLQ pain)

Ulcerative Colitis:

-Recurrent ulcerative and inflammatory disease of the mucosal and submucosal layers of the colon and rectum

Medical treatment of both crohn's disease and ulcerative colitis is aimed at:

-Reducing inflammation -Suppressing inappropriate immune responses -Providing rest for the bowel -Improving QOL -Prevent/minimize complications

What would you expect to see with a barium study if the diagnosis was crohn's disease?

-Regional, discontinuous skip lesions -Narrowing of the colon -Thickening of bowel wall -Mucosal edema -Stenosis, fistulas -Ulcerations (cobble stone)

Changing the appliance of a ileostomy:

-Regular schedule for changing a pouch before leakage should be established -Usually wearing time of the pouch is 5-10 days -The appliance should be emptied every 4-6 hours, or at the same time the pt. empties the bladder -Most pouches are disposable and odor proof

Nursing management goals for appendicitis:

-Relieving pain -Preventing fluid volume deficit -Reducing anxiety -Eliminating infection due to the potential or actual disruption of the GI tract -Maintaining skin integrity -Attaining optimal nutrition

Diverticulum:

-Saclike herniation of the lining of the bowel that extends through a defect in the muscle layer; 95% occur in the sigmoid colon

When can the a pt. who received surgery for appendicitis be discharged?

-Same day as the surgery if temp. is within normal limits no undue discomfort to the operative area, and the appendectomy was uncomplicated

Pharmacologic therapy for IBD:

-Sedatives -Antidiarrheals -Antiperistaltic -Aminosalicylates (sulfasalazine) are used for mild-moderate inflammation & are used to prevent recurrences in long-term maintenance -Corticosteroids are used to prevent severe and fulminant disease can be administered orally (prednisone) in outpatient treatment & parenterally (hydrocortisone) in hosp. pts. -Antibiotics for secondary infections (abscesses, perforation, and peritonitis) -Immunomodulators are used to alter the immunes system

Complications of peritonitis:

-Sepsis (major cause of death from peritonitis) -Shock may result from septicemia or hypovolemia -Intestinal obstruction (from the development of bowel adhesions)

Systemic complications of crohn's disease:

-Small bowel obstruction -Right-sided hydronephrosis -Nephrolithiasis -Chlelithiasis -Arthritis -Retinitis, iritis -Erythema nodosum

Foods that act as deodorizers in the intestinal tract:

-Spinach -Parsley *bismuth subcarbonate tablets may be prescribed and taken orally 3-4 times daily to reduce odor *oral diphenoxylate with atropine can be prescribed to thicken the stool which helps with odor *rice, mashed potatoes and applesauce may also thicken the stool helping with odor

Causes of peritonitis:

-Trauma/injury -Infection f/another site -Abdominal surgical procedures *-Peritoneal dialysis* -Appendicitis -Perforated ulcer -Diverticulitis -Bowel perforation

Crohn's disease:

-Subacute and chronic inflammation of the GI tract wall that extends through all layers -Common in the distal ileum and ascending colon

For the pt. who is febrile, has freq. diarrhea stools, or is bleeding the RN:

-Suggest bed rest -The pt. should still perform active exercises to maintain muscle tone and prevent thromboembolic complications -If the pt. cannot perform activities the nurse performs passive exercises and ROM

Parenteral nutrition is indicated in pts. with IBD when:

-There is severe malnutrition and intolerance of enteral nutrition that expected to last more than 1-2 weeks

*Complications of ulcerative colitis:

-Toxic megacolon -Perforation -Bleeding from ulceration -Vascular engorgement -Highly vascular granulation tissue

Systemic complications of ulcerative colitis:

-Toxic megacolon -Perforation -Hemorrhage -Malignant neoplasm -Pyelonephritis -Nephrolithiasis -Cholangiocarcinoma -Arthritis -Retinitis, iritis -Erythema nodosum

Does bleeding occur more in crohn's disease or ulcerative colitis?

-Ulcerative colitis -Bleeding does not usually occur in crohn's disease and if it does it is very mild

Intense lower abdominal pain that radiates to the legs, hematuria, and signs of dehydration indicates that the:

-Urine should be drained

When does perforation usually occur with appendicitis and what are the manifestations?

-Usually occurs 24 hours after the onset of pain -Fever of 100 degrees -Toxic appearance -Continued abdominal pain/tenderness -Pts. w/peritonitis caused from perforation are may be found supine & motionless

Manifestations of appendicitis:

-Vague epigastric or periumbilical pain (visceral pain that is dull and poorly localized) that progresses to the *RLQ* (partial pain that is sharp, discrete, and well localized) -Low-grade fever -Nausea -Vomiting -Loss of appetite -Constipation -Rebound tenderness (production of intensification of pain when pressure is released) -Local tenderness is elicited at McBurney's point -Rovsing's sign (when palpating the LLQ, the pain will be felt in the RLQ) -Psoas sign (pain that occurs upon slow extension of the right thigh with the pt. laying on the left side) -Obturator sign (pain that occurs with passive internal rotation of the flexed right thigh w/ the pt. supine)

Laparoscopy

-Visual (endoscopic) examination of the abdomen with a laparoscope inserted through small incisions in the abdomen

Regional enteritis occurs in what location:

-ileum, ascending colon (causes RLQ pain)

Peritonitis:

Inflammation of the peritoneum, which is the serous membrane lining the abdominal cavity and covering the viscera