Test#1 Ch 57 Peritonitis, Ulcerative colitis, crohn's
What are the CARDNIAL sign of peritonitis? Localized? Generalized?
*Abdominal pain, tenderness, and distention* *Localized* abdominal tenderness on palpation in a well-defined area with rebound tenderness in this area. *generalized* Tenderness is widespread
What are the First aminosalicylates approved for UC What glucocorticoids, Antidiarrheal and immunomodulators are use
*Aminosalicylates* Sulfasalazine (Azulfidine, Azuldidine EN-tabs) *Glucocorticoids* Prednisone 45 to 65 mg prednisolone *Antidiarrheal* diphenoxylate hydorochloride atropine sulfate (Lomotil) loperamide (Imodium) *immunomodulators* infliximab (Remicade) Adalimumab (Humira)
physcosocial Assesment of UC
*Assess understanding of the illness* *Encourage and support the patient while exploring* ~relationship of life event to disease exacerbation ~stress factors that produce symptoms ~~family and social support ~concerns regarding the possible genetic basis and associated cancer risks of the disease ~internet access for reliable education information
Chronic inflammatory disease of the small intestines (most often) , the colon or both
*Crohn's Disease*
What is the gastroenterologists classification o UC severity
*MILD* <4 stools/day with/without blood *Moderate* >4 stools/day with/without blood *SEVER* >6 bloody stools/Day *FULMINATE* >10 bloody stools/day
What are the S/S of the classifications Mild-Fulminte
*MILD* <4 stools/day with/without blood asymptematic, labs usually normal *MODERATE* >4 stools/day with/without blood minimal symptoms, mild abdominal pain, mild intermittent nausea, possible *increase in C-Reactive protein or ESR* *SEVER* >6 bloody stools/Day fever, tachycardia, anemia, Abdominal pain, *Elvevated C-Reactive protein or ESR* *FULMINANT* >10 bloody stools/Day Increasing symptoms, Anemeia *May require Transfusion*, colonic distention on x-ray
What other diagnostic Assessments are done
*Magnetic resonance enterography (MRG)* (major examination used to study the bowl in patients with IBD) ~Colonoscopy (may be done to aid in diagnosis) ~CT scan ~Barium enemas with air contrast
Fistula management
*Nursing priority is preserving and protecting the skin* *Adequate nutrition and fluid and electrolyte are priorities* Requires at least 300 calories daily to promote healing TEN or TPN maybe needed High calorie, high protein, high vitamin, low fiber meals offer enteral supplements such as ensure and vivonex Plus record food intake for accurate calorie count Record intake and output daily weights Collaborate with wound, ostomy and continence nurse,
What is The nutrition therapy and rest for these patients
*Sever symptoms* NPO/hospitalized, TPN *less sever symptoms* drink elemental formulas such as Vivonex PLUS or Vivonex T.E.N Activity is generally bedrest to promote comfort and healing
Creates widespread inflammation of mainly the rectum and recto sigmoid colon but can extend to the entire colon when the disease is extensive
*Ulcerative Colitis*
fluid is shifted from the extracellular fluid compartment into the peritoneal cavity connective tissue and GI track ("third spacing") *what can happen due to this shift?*
*hypovolemic shock *Acute kidney injury with impaired fluid and electrolyte balance *peristalsis slows or stops *lumen and bowl becomes distended with gas and fluid *bacteremia *septicemia *respiratory problems *pain
Teach the patient to refine from lifting at least for
*pen surgery*6 weeks *laparoscopic surgery can resume activities within week or two*
life-threatening acute inflammation and infection of the visceral/ parietal peritoneum and endothelial lining of the abdominal cavity is?
*peritonitis*
WBC are often elevated to
20,000/mm3 with high neutrophil count
What can form in these ulcerative areas and result in tissue necrosis (cell death)
Abscesses
What lab studies dose HCP request
Anemia is common ~Serum levels of folic acid and B12 general low ~amino acid malabsorption ~decrease albumin ~increase C-reactive protein and ESR ~WBC in the urine ~potassium and magnesium loss *X-ray* show narrowing, ulcerations, strictures and fistulas *MRE* determine bowel activities and motility *adominal ulersound or CT san* GI scan is done if GI bleeding of more that 0.5ml/min
What happens in more sever inflammation of the lining
Bleeding small erosion ulcers
What S/S will you see in a patient with Crohn's Disease
Diarrhea Abdominal pain ( RLQ) Low grade fever Steartorrhea (common) Pain around the umbilicus before and after BM Weight loss Chronic inflammation Anorexia Malabsorption Impaired fluid and electrolytes and vital nutrient deficiencies Anemia
what are symptoms to watch for with a ileostomy
Drastic or decrease in drainage Stoma smells, abdominal cramping, distention or if the ileostomy contents stop draining: ~remove the pouch faceplate ~lie down, assuming a knee-chest position ~begin abdominal Massage ~Apply moist towels to abdomen ~Drink hot tea ~If non of these maneuvers is effective in resuming ileostomy flow or if abdominal pain is sever, call the HCP right away
What are the bacteria's responsible for peritonitis
E-coli streptococcus staphylococcus pneumococcus gonococcus
Assessment what History should be collected
Family HX of IBS, previous and current therapy, dates and surgeries Nutrition HX Including tolerance of Milk, and milk product foods, spicy, hot foods. Elimination patterns Abodomial pain, tenesmus, anorexia, fatigue Relationship between diarrhea, timing of meals, emotional stress, and activity Inquire about exposure to antibiotics suggesting C-diff infection Have they traveled to or emigrated from tropical areas Ask about NSADS Ask about Extraintestinal symptoms such as Arthritis, mouth soars, vision problems and skin disorders
natakuzumab (Tysabri) is given every and can cause
IV every 4 weeks progressive multifocal leukoencephalopathy
what nationality is UC more common among
Jewish
postop care
NPO NGT IV fluids
What if the patient is critical ill would they still do surgery
No it would be delayed because it could be life-threatening
Physical Assessment/ Clinical manifestations
Note any abdominal distention along colon Fever associated with tachycardia (may indicate peritonitis, dehydration, or bowel perforation. check for inflamed joints and soars in the mouth
During inspection would observe for
Progressive abdominal distention and Bowel sounds will disappear
What procedure is the gold standard for UC
Restorative Protocolectomy with lleo Pouch-Anal Anastomosis (RPC-IPAA)
*What are the Key features of peritonitis*
Rigid, boadlike abdomen (classic) Abdominal pain distended abdomen N/V, anorexia diminishing bowel sounds inability to pass flatus or feces rebound tenderness in the abdomen High fever tachycardia dehydration from high fever (poor skin turgor) decrease urine output hiccups possible compromised respiratory status
preoperative care includes
Teaching about abdominal surgery and about the ileostomy. parental antibiotics are given 1 hr before
What are something's patient report
Tenesmus (an unpleasant and urgent sensation to defecate) lower abdominal colicky pain that is relieved with defection
Crohn's Disease presents as inflammation that causes a
Thickened bowel wall strictures and deep ulcerations put pt at risk for developing bowel fistulas that result in sever diarrhea and malabsorption of vital nutrients
What Labs are assessed
WBC Fluid and electrolytes BUN creatinine HBG hematocrit oxygen saturation and end carbon dioxide monitoring Abdominal X-ray Abdominal ultrasound
Most have symptoms and are diagnosed at what age
adolescent or young adults
What are the common drug therapy for UC
aminosalicylates glucocorticoids antidiarrheal immunomodulators
*Crohn's Disease* is made worse by
bacterial infection
What is the diagnosing age for UC
between 30-40 and then at 55-65 years of age
The patients stool typically contains what
blood and mucus
what is peritonitis most often caused by
contamination of the peritoneal cavity by: bacteria chemicals
what does surgery focus on
controlling the contamination, removing foreign material and draining collected fluid
Where are these patients often admitted to
critical care unit
Patients with large incisions healed by second or third intentions may require
dressing, solution and catheter-tipped syringes to irrigated the wound
what teaching should be done if the patient is having the *Magnetic resonance enterography (MRG)* test done
fast for 4-6 hr before drink contrast medium which can cause diarrhea pt. has time to use the bathroom before being placed on the MRI table patient lies PRONE while the first two dose of glucagon are given SUBQ
what drug can be effective but can cause sepsis resulting from an abscesses or fistula that is present
glucocorticoids (they mask symptoms of infection)
What are the complementary and alternative therapies used
herbs (fleexseed) selenium vitamin C Biofeedback hypnosis yoga acupuncture Ayurveda
The intestinal mucosa becomes
hyperemic (increase blood flow) edematous reddened
How will the patient most often appears
ill, lying still, knee flexed, guarding, coughing, may show or report pain
What are the older patients at High risk for
impaired fluid and electrolyte balance , result of diarrhea, dehydration and hypokalemia
what are some common used drugs for patients with CD but are not give to patients with hx of cancer, heart disease or MS
infliximab (Remicade) adalimumab (Humira) natakuzumab (Tysabri) (IV every 4eeks) certolizumab pegol (Cimzia)
What are the chemical cause
leakage of Bile, pancreatic enzymes, gastric acid
What does the stool look like initially after surgery
loose, dark green liquid that may contain some blood
What symptoms are common
malaise anorexia anemia dehydration fever weight loss
GI secretions are high in volume and rich in electrolytes and enzymes. Patients with a fistula are at high risk for
malnutrition, dehydration, hypokalemia,
What are some factors causing exacerbation
many including intestinal infections
what drug had been helpful in pt with fistulas
metronidazole (Flagyl, Novonidazol)
Fistulas formation is more common in but rare in
more common in Crohn's Disease rare in UD
continue edema and mucosal Thickening can lead to what and possibly a ?
narrowed colon partial bowel obstruction
UC is a disease that is a associated with
periodic remission and exacerbation (flare-ups)
What Extraintestinal manifestation are reported in a large number of patients
polyarthritis ankylosing spondylitis erythema nodosum
What is the surgical management
require surgery temporary or permanent ileostomy is planed
What are the laboratory Assessments for UC
result of chronic blood loss ~*LOW* HBG, Hematocrit levels *Increase* WBC, C-reactive Proteins, or erythrocyte sedimentation rate (ESR *Low* Na, K, CL Hypoalbumiemia (decrease serum albumin)
Drug therapy is What are two agents that may be prescribed for CD What might also be given
similar to UC azathioprine (Imuran) mercaptopurine (Purinethol) metgitrexate (MTX)
how does *Crohn's Disease* progress
slowly and unpredictable
when dose the ileostomy begin to drain after surgery and how much is expected
with in 24hr 1L/day
What gender does it effect more in
women ore than men in the younger years and Men more often as middle aged and older adults
what assessment questions should be asked
~Abdominal Pain (cramping, sharp, aching, location of pain, is it localized or generalized. ~Ask about low-grade fevers or spikes in temp ~
What are surgical interventions
~Exploratory laparotomy is opening into the abdomen ~laparoscopy used to remove or repair the inflamed or perforated organ
What are the complications of Ulcerative Colitis and Crohn's disease
~Hemorrhage/perforation ~Absess formation ~Toxix megacolon ~Malabsorption (most common in crohn's) ~Nonmecahanical bowel obstruction ~Fistulas (in crohns inflammation is transmural) ~Colorectal cancer Extraintstinla complications ~Osteoporosis (especially patients with Crohn's)
what are some non-surgical Interventions
~Hypertonic fluids ~Broad spectrum antibiotic ~IV fluids used to replace fluids collected in the peritoneum and bowl. ~daily weights ~Intake and out puts ~NGT decompress the stomach ~NPO ~OXYGEN ~Analgesics ~monitor pain control ~document pain assessment
physical findings depends on several factors such as
~stage of the disease ~The ability of the body to fight of infection and weather if the inflammation has progressed to generalized peritonitis
What should be instructed to the patient and family to report immediately to the HCP once they patient goes home ?
~unusual or foul smelling drainage ~swelling, redness or warmth or bleeding from the incision site ~temp high than 101 ~abnormal pain ~signs of wound dehiscence or ileus
