Med Surg: Lower GI
non-surgical treatment of diverticulitis
-NPO -NG tube to suction -low fiber diet until signs of infection are gone -avoid indigestible roughage -increase fluids -avoid increased intra-abdominal pressure
interventions for constipation
-mobilize -increase fiber and fluids -judicious use of laxatives (avoid laxative dependence) -enemas -biofeedback -position
diagnosis of diarrhea
-need thorough history (stool pattern, travel, diet, medications, surgery) -*fecal culture*- ova & parasites -CBC, BUN, electrolytes -colonoscopy -iron & folate levels
diagnosis of IBD
-stool characteristics- blood, frequency, volume -abdominal pain and tenderness location -nutritional status - H&P- differentiates between IBD -Barium studies (swallow and/or enema) -CBC, BMP, fecal occult blood test, stool cultures -CT of abdomen -colonoscopy is most diagnostic -Crohn's-sedementation rate is elevated
surgical teaching for IBD
-teach patient BEFORE surgery- wound care consult -visit from patient with ostomy (ostomate) -Initially NG tube and NPO
The nurse is irrigating a colostomy when the patient says, "You will have to stop, I am cramping so badly." What is the priority action by the nurse?
Clamp the tubing and give the patient a rest period. When irrigating a colostomy, the nurse should allow tepid fluid to enter the colon slowly. If cramping occurs, the nurse should clamp off the tubing and allow the patient to rest before progressing. Water should flow in over a 5- to 10-minute period.
Celiac sprue is an example of which category of malabsorption?
Mucosal disorders causing generalized malabsorption In addition to celiac sprue, regional enteritis and radiation enteritis are examples of mucosal disorders. Examples of infectious diseases causing generalized malabsorption include small-bowel bacterial overgrowth, tropical sprue, and Whipple disease. Examples of luminal problems causing malabsorption include bile acid deficiency, Zollinger-Ellison syndrome, and pancreatic insufficiency. Postoperative gastric or intestinal resection can result in development of malabsorption syndromes.
The nurse is caring for a client with intussusception of the bowel. What does the nurse understand occurs with this disorder?
One part of the intestine telescopes into another portion of the intestine. In intussusception of the bowel, one part of the intestine telescopes into another portion of the intestine. When the bowel twists and turns itself and obstructs the intestinal lumen, this is known as a volvulus. A hernia is when the bowel protrudes through a weakened area in the abdominal wall. An adhesion is a loop of intestine that adheres to an area that is healing slowly after surgery.
Ulcerative Colitis patho
*Inflammatory Bowel disease* -edema and inflammation of the rectum and may progress to the sigmoid colon and may expand the length of the colon -usually begins in the rectum and the distal colon involving the mucosa and submucosa -bowel obstruction may occur and intestinal mucosal cell change may cause *colon cancer* or insufficient production of intrinsic factor, which is necessary for the absorption of vitamin B12 -insufficient amounts of B12 may lead to *pernicious anemia*
Crohn's Disease patho
*Inflammatory bowel disease* -Inflammation and ulceration of the GI tract, often at the distal ileum. -All bowel layers become involved, and lesions are not continuous but sporadic. -Fistulas are common -Can involve the entire GI tract from the mouth to the anus (also called Regional enteritis) -Malabsorption and malnutrition may develop when jejunum and ileum become involved -Supplemental vitamins and minerals including vitamin B12 injection may be necessary
diarrhea
*symptom not disease* -leading cause of child mortality and morbidity in the world -acute or chronic (>4 weeks) -tenesmus -fluid volume deficit (dehydration) -electrolyte imbalance (hypokalemia, hypomagnesemia) -acid-base imbalance (metabolic acidosis) -malabsorption/malnutrition -perianal skin irritation -systemic=fever, N/V, malaise -can be caused by fecal impaction
IBD treatment diet
-*low residue, high protein, high calorie, vitamins, and iron* -avoid whole grains (contributes to diarrhea) -*TPN* if malnourished -avoid smoking and caffeine -avoid anything that increases motility (low fiber)
diagnosis of diverticulosis/diverticulitis
-X-rays (barium enema usually not done during acute phase due to risk of perforation) -CT scan -colonoscopy, sigmoidoscopy -CBC
home treatment of diverticulitis
-antibiotics (flagyl, cipro) -analgesics -antispasmodics -bowel rest & rest
IBD medications
-antibiotics (if infection present) -steroids (try to use only for exacerbation to avoid complications) -iron, vitamins -anticholinergics (slow gut down- Librax) -anti-diarrheals (use sparingly and don't really work for bad cases) -immunosuppressives: Immuran, cyclosporine, methotrexate -Sulfasalazine, Azulfadine- 1st line- decrease inflammatory response -Tumor necrosis factor inhibitor
treatment of appendicitis
-antibiotics and IV fluids -surgery: laparoscopic or open -advance diet as tolerated -LMWH and mobilize! -all other post-op precautions
signs/symptoms of diverticulitis
-bowel irregularity -LLQ pain (sigmoid colon); cramping -fever, increased WBC -nausea, anorexia -occult bleeding (10-30%)
bowel obstruction
-can occur from mechanical or non-mechanical causes -mechanical causes usually require surgery -symptoms vary according to location- more common in small intestines -bowel sounds are hyperactive above obstruction and hypoactive below obstruction -herniation, adhesions, volvulus, intussusception
colonoscopy
-clear liquid diet for 12-24 hours -NPO 6-8 hours pre-procedure -Avoid NSAIDs, aspirin -Laxatives or enemas until clear -Polyethylene glycol (Go-LYTELY) -sedated for procedure -post procedure watch for bleeding, signs of perforation- pain or unusual discomfort
treatment for diarrhea
-depends on cause -fluid and electrolyte replacement -*anti-diarrheals (Immodium, Lomotil, Donnagel)- contraindicated with food poisoning* -antibiotics
Crohn's signs/symptoms
-diarrhea and steatorrhea (excess fat in feces) -crampy pain often confused with appendicitis -severe weight loss -malnutrition -anemia -fever -abscess -fistula -severe inflammtion -usually not curative, transmural inflammation -stools less bloody and less frequent than ulcerative colitis -transmural skip lesions ("cobblestone") -prone to strictures and fistula formation
surgical treatment of diverticulitis
-emergency surgery if peritonitis or pelvic abscess -colon resection (with or without colostomy) -NPO with NGT until peristalsis returns -advance diet with return of peristalsis and bowel sounds
signs/symptoms of appendicitis
-generalized pain initially- eventually localizes to the right lower quadrant (Mcburney's Point) -rebound tenderness -N/V, anorexia -pain occurs 1st, N/V occur later
large bowel obstruction
-gradual onset of pain -low-grade, cramping pain -vomiting is rare -lower abdominal distention -obstipation- intestinal obstruction, severe constipation -no major fluid and electrolyte imbalance -metabolic acidosis
signs/symptoms of bowel perforation/peritonitis
-guarding of abdomen -increased fever and chills -pallor -pain caused by coughing (peritonitis) -pain relieved by right hip flexion (peritonitis) -abdominal distention and pain -restlessness and tachypnea
diverticulosis
-herniation into the intestinal wall that frequently occurs in the colon (usually sigmoid) -frequent episodes of inflammation from trapped feces or bacteria may lead to bleeding and infection -may perforate and cause peritonitis
controlling diverticulosis
-high fiber (uncomplicated diverticulosis) -exercise -stool softeners -avoid indigestible roughage- nuts, popcorn, corn, bean, lentils, fruits with skin-rasberries, cranberries
colostomy care
-if in ascending or transverse colon, stools are semi-liquid -if in descending or sigmoid colon, stools are semi-formed or formed (should be irrigated for regularity) -best time to irrigate=same time every day, after a meal -when irrigating an ostomy, same principles are used as if you were administering an enema
diverticulitis
-inflammation and infection of diverticula -most common in >60 years old -associated with low fiber diet -contributing factors: constipation and obesity -only about 10% of clients who have diverticulosis develop diverticulitis
causes of constipation
-low fiber diet -decreased activity -low fluid intake -bed rest -prolonged retention (decreased muscle tone) -polypharmacy- opioids/pain management meds
diagnosis of appendicitis
-low grade temp (high temp=ruptured appendix/peritonitis) -elevated WBC (10-18; if over 20- ruptured appendix/peritonitis) -ultrasound and/or CT of abdomen -avoid laxatives, enemas, heat- worried about rupture -NPO -Ice to RUQ
tumor necrosis factor inhibitor
-monoclonal antibody -used in moderate to severe Crohn's for unresponsive to standard treatment -used in UC in conjunction with steroids (Remicade, Tysabri, Humira) -neutralizes TNF which is the protein responsible for much of intestinal inflammation -reduces symptoms in 82% -very expensive- not 1st line treatment
Ulcerative Colitis signs/symptoms
-profuse bloody diarrhea (worse than Crohn's) -abdominal pain (colicky and relieved by defecation) -bloated, inflated colon with distention -anemia -severe tenesmus -borborygmi (rumbling/gurgling of bowel sounds) -more common than Crohn's, not transmural -usually confined to colon and rectum -continuous rather than "skip" lesions -perforation may occur -cured by total removal of colon and rectum -increased incidence of colon cancer
small bowel obstruction
-rapid pain onset -colicky and cramping pain -frequent copious vomiting -upper abdominal distention (bacteria) -bowel movements may continue for short time -severe fluid and electrolyte imbalance -metabolic alkalosis
IBD treatment
-rest bowel/control diarrhea -control inflammation, control infection if present -control abdominal pain -restore blood volume (anemia) -correct electrolyte imbalance -control nutritional deficiencies -monitor for complication -diet modifications -medications
surgical interventions for Crohn's
-surgery is a last resort -may remove only the affected area -client may get ileostomy or colostomy depending on area affected
surgical interventions for ulcerative colitis
-total colectomy with ileostomy formed (curative) -Koch's ileostomy or J pouch- no external bag -A Koch's pouch has a nipple valve that opens and closes to empty intestines using a catheter -J pouch (most popular) procedure removes the colon and attaches the ileum to the rectum
ileostomy care
-will drain liquid (do not need to irrigate) and patient must wear a pouch system at all times -empty when pouch is 1/2 to 1/3 full- change system q 3-5 days -avoid high fiber foods (hard to digest and rough foods increase motility) -patients are prone to dehydration- encourage fluids/ gatorade in summer
Surgery is required for ___-___% of IBD patients
15-20
The nurse is assisting a client to drain his continent ileostomy (Koch pouch). The nurse should insert the catheter how far through the nipple/valve?
2 in. The nurse should insert the lubricated catheter about 2 inches (5 cm) through the nipple/valve.
The nurse is performing an abdominal assessment for a patient with diarrhea and auscultates a loud rumbling sound in the left lower quadrant. What will the nurse document this sound as on the nurse's notes?
Borborygmus Borborygmus is a rumbling noise caused by the movement of gas through the intestines, often associated with diarrhea.
A client informs the nurse that he has been having abdominal pain that is relieved when having a bowel movement. The client states that the physician told him he has irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder?
Chronic constipation with sporadic bouts of diarrhea Most clients with irritable bowel syndrome (IBS) describe having chronic constipation with sporadic bouts of diarrhea. Some report the opposite pattern, although less commonly. Most clients experience various degrees of abdominal pain that defecation may relieve. Weight usually remains stable, indicating that when diarrhea occurs, malabsorption of nutrients does not accompany it. Stools may have mucus, but blood is not usually found because the bowel is not locally inflamed. The sleep is not disturbed from abdominal pain.
A patient with irritable bowel syndrome has been having more frequent symptoms lately and is not sure what lifestyle changes may have occurred. What suggestion can the nurse provide to identify a trigger for the symptoms?
Keep a 1- to 2-week symptom and food diary to identify food triggers. The nurse emphasizes and reinforces good dietary habits (e.g., avoidance of food triggers). A good way to identify problem foods is to keep a 1- to 2-week symptom and food diary.
The nurse is assessing a patient with appendicitis. The nurse is attempting to elicit a Rovsing's sign. Where should the nurse palpate for this indicator of acute appendicitis?
Left lower quadrant Rovsing's sign may be elicited by palpating the left lower quadrant; this paradoxically causes pain to be felt in the right lower quadrant (see Fig. 48-3).
Diet modifications for patient diagnosed with chronic inflammatory bowel disease include which of the following?
Low residue Oral fluids and a low-residue, high-protein, high-calorie diet with supplemental vitamin therapy and iron replacement are prescribed to meet the nutritional needs, reduce inflammation, and control pain and diarrhea.
Which of the following will the nurse observe as symptoms of perforation in a patient with intestinal obstruction?
Sudden, sustained abdominal pain Sudden, sustained pain, abdominal distention, and fever are symptoms of perforation in a client with intestinal obstruction. A decrease in blood pressure and decrease in urine output are symptoms of shock. Purulent drainage from the gluteal fold is not a symptom of perforation; it only indicates that the client has developed a condition of anorectal abscess.
A client who has undergone colostomy surgery is experiencing constipation. Which intervention should a nurse consider for such a client?
Suggest fluid intake of at least 2 L/day The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.
Which is a true statement regarding regional enteritis (Crohn's disease)?
The clusters of ulcers take on a cobblestone appearance. The clusters of ulcers take on a cobblestone appearance. It is characterized by remissions and exacerbations. The pain is located in the lower right quadrant. The lesions are not in continuous contact with one another and are separated by normal tissue.
The presence of mucus and pus in the stools suggests which condition?
Ulcerative colitis The presence of mucus and pus in the stools suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.
Patients diagnosed with malabsorption syndrome may have vitamin and mineral deficiency. Patient who easily bleed have which of the following deficiencies?
Vitamin K The chief result of malabsorption is malnutrition, manifested by weight loss and other signs of vitamin and mineral deficiency (e.g., easy bruising [vitamin K deficiency], osteoporosis [calcium deficiency], and anemia [iron, vitamin B12 deficiency]).
complications of diverticulosis/diverticulitis
abscess, fistula, perforation, obstruction (edema), adhesions, peritonitis, usually hospitalize if temp is >101, persistent or severe abdominal pain >3 days, and/or lower GI bleed
complications of IBD
abscess, intestinal obstruction (fairly common), fistula formation (Crohn's), perianal disease, anemia, fluid & electrolyte imbalance
A 72-year-old client seeks help for chronic constipation. Constipation is a common problem for elderly clients because of several factors related to aging, including:
decreased abdominal strength. Decreased abdominal strength, muscle tone of the intestinal wall, and motility all contribute to chronic constipation in the elderly. A decrease in hydrochloric acid causes a decrease in absorption of iron and vitamin B12, whereas an increase in intestinal bacteria actually causes diarrhea.
A client has symptoms suggestive of peritonitis. Nursing management would not include:
limiting analgesics to avoid the formation of paralytic ileus. Analgesics such as meperidine or IV morphine sulfate are ordered to relieve pain and promote rest. Because hypovolemia can occur from fluids leaking into the peritoneal cavity, input and output are monitored closely to assist in determining fluid replacement. A nasogastric tube is used to relieve abdominal distention by suctioning the accumulated gas and stagnant upper GI fluids. If hypovolemia is present, renal perfusion can become decreased, requiring close monitoring.
Nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. The nurse also expects to find:
severe abdominal pain with direct palpation or rebound tenderness. Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (such as appendicitis, diverticulitis, ulcerative colitis, or a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.
appendicitis
small projection of the cecum becomes trapped with hard material (usually feces) that leads to bacterial infection, the lumen becomes blocked and edematous, which leads to abdominal pain (most common indication for an abdominal surgery)
