med surg 1: ch 57 care of patients with inflammatory intestinal disorders

appendicitis s/s

-Abdominal pain followed by nausea and vomiting can indicate appendicitis •Appendicitis presents with cramp like pain in the epigastric or periumbilical area. • Anorexia with nausea and vomiting is a frequent symptom. • Initially pain can present anywhere in the abdomen or flank area. • As inflammation and infection progress, the pain becomes more severe and shifts to the Right Lower Quadrant at the *McBurney's Point* (between the anterior iliac crest and the umbilicus) • Abdominal pain that increases with cough or movement and is relieved by bending the right hip or the knees suggests perforation and peritonitis. • Assess for muscle rigidity and guarding on palpation of the abdomen. • Patient may report rebound tenderness pain.

kinds of chronic inflammatory bowel diseases (2)

1. ulcerative colitis 2. crohns disease

appendicitis basics

Appendicitis is an acute inflammation of the vermiform appendix that occurs most often among young adults. • It is the most common cause of right lower quadrant pain. • Inflammation occurs when the lumen of the appendix is obstructed, leading to infection as bacteria invade the wall of the appendix. • The initial obstruction is usually a result of fecaliths (very hard pieces of feces) composed of calcium phosphate-rich mucus and inorganic salts.

ileostomy

a procedure where a loop of the ileum is placed through an opening of the abdominal wall (stoma) for drainage of fecal material into a pouching system worn on the abdomen.

toxic megacolon

massive dilation of the colon that can lead to gangrene and peritonitis), hemorrhage, dysplastic biopsy results, and colon cancer. -can help manage ulcerative colitis

Total Proctocolectomy with a Permanent Ileostomy

• Removal of the colon, rectum, and anus with surgical closure of the anus. • The end of the ileum is brought out through the abdominal wall and forms a stoma, or ostomy. • Stool empties into external pouch system. **Skin care around the soma is priority**

peritonitis patho

• A life threatening, acute inflammation and infection of the visceral/parietal peritoneum and endothelial lining of the abdominal cavity. • Normally the peritoneal cavity contains about 50ml of sterile fluid (transudate), which prevents friction during peristalsis. • When contaminated by bacteria the body begins an inflammatory reaction, causing vascular dilation and increased capillary permeability, allowing transport of leukocytes and subsequent phagocytosis. • Bacteria gain entry into peritoneum by perforation (from appendicitis, diverticulitis, peptic ulcer disease) or from an external penetrating wound, a gangrenous gallbladder, bowel obstruction, or ascending infection through genital tract. • Common bacteria responsible - Escherichia coli, Streptococcus, Staphylococcus, Pneumococcus, and Gonococcus.

anal fissure

• A tear in the anal lining, can be very painful. • Smaller fissures occur with straining to have a stool. • Larger fissures from another disorder (Crohn's, tuberculosis, leukemia, neoplasm) or from trauma (foreign body, anal intercourse, perirectal surgery) • Acute fissure usually resolves on its own. • Chronic fissures recur and might require surgery. • Manifestations - Pain during defecation, bright red blood in stool, pruritus, urinary frequency or retention, dysuria, and dyspareunia (painful intercourse) • Treatment - local pain relief and softening stools. Warm sitz bath, analgesics and bulk producing agents(Metamucil), topical agents (hydrocortisone creams and suppositories)

anal fistula

• Abnormal tract leading from anal canal to the perianal skin. • Usually as a result of anorectal abscesses caused by obstruction of anal glands. • Can occur with Crohns, tuberculosis, or cancer. • Does not heal on its own, surgery necessary. Surgeon opens the tissue and scrapes the base.

gastroenteritis assessment

• Ask about recent travels, especially tropical regions of Asia, Africa, Central or South America. • Eaten at a restaurant in the past 24-36 hours. • Contaminated spinach or lettuce • Patient usually looks ill • Nausea and vomiting, followed by abdominal cramping and diarrhea • Older patients - monitor for hypokalemia and hypovolemia.

peritonitis assessment

• Auscultate for bowel sounds, which usually disappear with progression of the inflammation. • Assess for abdominal wall rigidity ("boardlike" abdomen) • Observe for dry mucous membranes and low urine output. • Lab tests to assess fluid/electrolyte balance, renal status, BUN, creatinine, hemoglobin, and hematocrit. • X-ray or ultrasound can assess for free air or fluid in abdominal cavity, indicating perforation. • General post-op care.

celiac disease

• Chronic inflammation of the small intestinal mucosa that can cause bowel wall atrophy and malabsorption. • Primary complication is cancer, specifically non-Hodgkin's lymphoma or GI cancers. • Cycles of remission and exacerbation. • In adults 30-50 yrs. • A multi-system autoimmune disease. • People with other autoimmune diseases like rheumatoid arthritis and diabetes mellitus type 1 at highest risk. • Symptoms - Anorexia, diarrhea/constipation, steatorrhea, abdominal pain, bloating, distention, weight loss. • Some patients have no symptoms, some have atypical symptoms that affect every body system. • Dietary management is the only treatment for achieving disease remission. • Gluten free diet results in healing intestinal mucosa after about 2 years

crohns disease

• Chronic inflammatory disease of the small intestine (most often), the colon, or both. • Can affect GI tract from the mouth to the anus but most commonly affects the terminal ileum. • Slowly progressive and unpredictable disease with involvement of multiple regions of intestine with normal section in between (called "skip lesions" on x-rays). • Is recurrent with remissions and exacerbations. • Presents as inflammation that causes a thickened bowel wall. -Strictures and deep ulcerations (cobble stone appearance) also occur which puts patient at risk for developing bowel fistulas- abnormal openings between two organs or structures. -Result is severe diarrhea and malabsorption of vital nutrients. -Anemia is common • Fistulas can occur between segments of intestine, cutaneous fistulas, perirectal abscesses, can extend from bowel to other organs and body cavities, such as the bladder or vagina. • Intestinal obstruction can occur secondary to inflammation and edema. -Fibrosis and scar tissue develop and obstruction results from a narrowing of the bowel. • Most patients require surgery at some point. • Most people are diagnosed as adolescents or young adults.

gastroenteritis patho

• Common health problem worldwide, causing diarrhea and/or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract. • Viral or bacterial infection of the small bowel. • Usually lasts 3 days. • Immunosuppressed or older adults, dehydration and hypovolemia can occur. • Norovirus occurs in places where large groups of people are in close proximity. (prisons, cruise ships, nursing homes, college dorms)

diverticular disease

• Diverticula - Pouchlike herniations of the mucosa through the muscular wall of any portion of the gut but most commonly the colon. • Diverticulosis - The presence of many abnormal pouchlike herniations in the wall of the intestine. • Acute Diverticulitis - inflammation of the diverticula.

ulcerative colitis etiology/ genetic risk

• Exact cause unknown • Combo of genetic, immunologic, and environmental factors likely contribute to disease development. • Often found in families and twins.

gastroenteritis interventions

• Fluid replacement. Amount and route determined by hydration status and overall health (Gatorade, Pedialyte, Powerade) • No drugs that suppress intestinal motility - can prevent the infecting organism from being eliminated from the body. • loperamide (Immodium) 4mg can be given orally, followed by 2mg after each loose stool, up to 16mg daily. • For bacterial infection with fever and severe diarrhea - ciprofloxacin (Cipro), levofloxacin (Levaquin), or azithromycin (Zithromax). • If the gastroenteritis is due to shigellosis, anti-infective agents such as trimethoprim/sulfamethoxazole (Septra DS, Bactrim DS, Roubac) or ciprofloxacin are prescribed. • Irritation due to frequent wiping- teach thorough drying, application of creams/oils, sitz bath

peritonitis interventions

• IV fluids and broad-spectrum antibiotics immediately after diagnosis. • Monitor daily weight and I/O. • NPO and nasogastric tube. • Analgesics and monitor pain control. • Surgery focuses on controlling the contamination, removing foreign material from peritoneal cavity and draining collected fluid. • Irrigation of the peritoneum with antibiotic solutions. • General post-op care. • No lifting for 6 weeks • Resume activities within a week or two. Home care, assess for: • Unusual or foul-smelling drainage • Swelling, redness, or warmth or bleeding from the incision site • A temperature higher than 101° F (38° C) • Abdominal pain • Signs of wound dehiscence or ileus

appendicitis nursing interventions

• Keep patient NPO to prepare for surgery and avoid making inflammation worse. • Administer IV fluids • If tolerated, maintain semi-Fowlers position so if there is any abdominal drainage it can be contained in the lower abdomen. • Administer pre-op opioid analgesics and antibiotics.' • No laxatives or enemas. • Do not apply heat to abdomen (can increase inflammation and perforation) Surgery is required as soon as possible • Appendectomy is the removal of the inflamed appendix. • Usually done by laparoscopy. (Typically discharged same day. Return to usual activities in 1-2 weeks) • A Laparotomy is an open surgical approach with a large abdominal incision for complicated or atypical appendicitis or peritonitis. (Hospitalized 3-5 days. Return to normal activity in 4-6 weeks)

restorative proctocolectomy with ileo pouc-anal anastomosis

• Laparoscopic removal of the colon and most of the rectum. • Anus and anal sphincter remain intact. • Surgeon creates an internal pouch (reservoir) using last 1 ½ feet of the small intestine. Called a J-pouch, S-pouch, or pelvic pouch is connected to the anus.

anorectal abscess

• Localized area of induration and pus caused by inflammation of the soft tissue near the rectum or anus. • Result of obstruction of the ducts of the glands in the anorectal region. • Feces, foreign bodies, or trauma can be the cause of the obstruction and stasis, leading to infection that spreads into nearby tissue. • Rectal pain is first symptom. Local swelling, redness, tenderness, itching follow. • Managed by surgical incision and drainage (I&D), or surgical removal. • Systemic antibiotics only given to pts who are immunocompromised, diabetic, have valvular disease or a prosthetic valve, or are obese.

parasitic infection

• Parasitic entry through mouth(oral-fecal transmission) from contaminated food or water, oral-anal sexual practices, or contact with feces from contaminated person. • Giardia lamblia, which causes giardiasis; Entamoeba histolytica, which causes amebiasis (amebic dysentery); Cryptosporidium. • Handwashing is best prevention.

peritonitis s/s

• Patient often appears acutely ill, lying still, possible with knees flexed. • Movement is guarded • Observe for progressive abdominal distention. • High fever due to the infectious process. • Tachycardia in response to fever and decreased circulating blood volume. • Nausea and vomiting • Hiccups may occur as a result of diaphragmatic irritation. • WBC count elevated to 20,000/mm3 with high neutrophil count. ** The cardinal signs of peritonitis are abdominal pain, tenderness, and distention. * • Localized - Abdomen is tender on palpation in a well defined area with rebouns tenderness in this area. • Generalized - Tenderness is widespread.

ulcerative colitis incidence and prevalence

• Peak age is 30-40 years old, and again at 55-65. • Women more affected in their younger years, men in middle and older age. • More common among Jewish people and white people.

ulcerative colitis nutrition therapy and rest

• Pts with severe symptoms who are hospitalized are kept NPO to ensure bowel rest. • Possible total perenteral nutrition (TPN) in severe cases • Formulas such as Vivonex PLUS or Vivonex T.E.N, which are absorbed in the small bowel and reduce bowel stimulation. • Caffeine and alcohol increase diarrhea and cramping. • Raw vegetables and other high fiber foods can cause GI symptoms in some pts • Limit lactose containing foods. • Carbonated beverages, pepper, nuts, corn, dried fruits and smoking are common GI stimulants. • Bed rest can reduce intestinal activity, provide comfort, and promote healing. • Ensure pt has easy access to bedpan, or bathroom.

ulcerative colitis patho

• Widespread inflammation of mainly the rectum and rectosigmoid colon -can extend to the entire colon • Can remain constant for years with periods of remission and exacerbations. • Intestinal mucosa becomes hyperemic (increased blood flow), edematous, and reddened. • If severe the lining can bleed and small ulcers can occur. • Continued edema and mucosal thickening can lead to narrowed colon and possible partial bowel obstruction. • Stool contains blood and mucus. • Patient reports *tenesmus* (an unpleasant and urgent sensation to defecate) -Lower abdominal colicky pain relieved with defecation • Malaise, anorexia, anemia, dehydration, fever, and weight loss are common.