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