Gastrointestinal Case Studies Flashcards by Kelsey Klipfel

Over 50 years of age
Long term smoking - sig
Other risk factors: genetics (family history - may get screened earlier), high fat diet (lot fast food), low activity, high ETOH (alchol) intake, hx of polyps, crohns, ulcerative colitis, H pylori, HPV, obesity

What risk factors did this client have for colorectal cancer?

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Rectal bleeding
Anemia
Change in stool consistency or shape - obstruction/tumor can change shape or can have change in consistency

What are the most common signs/symptoms of colorectal cancer?

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CBC may show decreased H/H - thinking about anemia
Fecal occult blood testing (positive)
Carcinoembryonic antigen (CEA) may be elevated - not specific to colorectal cancer; tell might have cancer
CT scan
Colonoscopy: definitive test for the diagnosis
Liver function tests: may be elevated if metastasis to the liver has occurred

What types of diagnostic tests would be appropriate to gather more information about Mr. Moore’s condition and what might the laboratory tests show if he has colorectal cancer?

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Screening at age 50 - colonoscopy
Fecal occult blood testing and colonoscopy every 10 years
Diet – decrease fat and refined carbohydrates and increase fiber, eat baked or broiled foods, not fried food
Avoid smoking and heavy alcohol consumption
Increase physical activity

What health promotion and maintenance interventions should patients practice to avoid a colorectal cancer diagnosis?

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Radiation
Chemotherapy
Surgery

Colon cancer treatment

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Based on size of tumor, location, metastasis
Colon resection
Colectomy
Abdominoperineal (AP) resection

Surgery - Colon cancer treatment

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Remove tumor and any lymph nodes

Colon resection

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Remove colon with a colostomy or ileostomy

Colectomy

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Remove sigmoid colon, rectum and anus

Abdominoperineal (AP) resection

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The nurse is teaching a patient with colorectal cancer how to care for a newly created colostomy. Which patient statement reflects a correct understanding of the necessary self-management skills?
A. I will have my spouse change the bag for me
B. If I have leakage, I should reinforce the barrier with tape
C. A dark purple stoma is normal and would not concern me
D. I will apply nonalcoholic skin sealant around the stoma and allow it to dry prior to applying the bag

Answer: D
Alcohol: burning, dry it out, irriation

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A clear ostomy pouch will be in place to allow for visualization of stoma
Assess the color and integrity of the stoma frequently
Should start functioning in 2-3 days
Stool consistency depends on where in the colon the stoma was placed:
Bag should be emptied when ⅓ to ½ full to prevent pulling
Entire Pouch (appliance) should be changed every 3-7 days
Lots of education needed - permanent/temp

Colostomy care

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Many different types, will depend on where the stoma is located, how active the patient, size and curve of abdomen

A clear ostomy pouch will be in place to allow for visualization of stoma

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Healthy stoma should be reddish or pink and moist and protrude about ¾ inch (2 cm) from the abdominal wall
May be slightly edematous and have a small amount of bleeding initially

Assess the color and integrity of the stoma frequently

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Liquid: ascending colon or if has an ileostomy
Pasty: tranverse colon
More solid: descending colon and sigmoid

Stool consistency depends on where in the colon the stoma was placed:

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Check surrounding skin, keep good seal, good assessment of stoma

Entire Pouch (appliance) should be changed every 3-7 days

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Collaborate with CWON for education and ongoing stoma and pouch care
Good edu - wound care to know educated good as well

Lots of education needed - permanent/temp

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Bowel is physically blocked by problems outside the intestine, in the bowel wall or within intestinal lumen
Ex. adhesions (outside) Crohn’s (within bowel walls), tumors (within intestinal lumen)
Most common causes in patients over 65 is diverticulitis, tumors, or fecal impaction

Describe the causes of mechanical intestinal obstructions.

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Paralytic ileus
peristalsis is decreased or absent
Most common cause handling of the intestines during abdominal surgery

Describe the causes of nonmechanical intestinal obstructions.

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Abdominal discomfort or pain
Visible peristaltic waves when observing abd
Upper or epigastric abdominal distention
Nausea and early on
Profuse vomiting
Obstipation - severe constipation; no gas/stools

Small bowel obstruction

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Intermittent lower abdominal cramping
Lower abdominal distention
Minimal or no vomiting
Obstipation or ribbon-like stools - going around obstruction
No major fluid and electrolyte imbalances - not vomiting; more absorption
High pitched bowel sounds transitioning to absent bowel sounds

Large bowel obstruction

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NPO
NGT including suction - lots output quickly and improves quickly esp if small bowel obstruction
Assess and record passage of flatus and character of bowel movements
Monitor VS
IVF - IV fluids; not want dehydration since vomiting
Weight
I/O
Assess and treat pain
Monitor for complications

What interventions are appropriate for Mrs. Jump’s SBO?

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Indicative that peristalsis has returned

Assess and record passage of flatus and character of bowel movements

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Monitor electrolyte imbalances

I/O

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Cautiously use opioids to treat pain secondary to slowing movement on GI tract - further causing constipation - depends on how bad pain; do other things if possible

Assess and treat pain

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Bowel perforation Ischemic bowel Peritonitis - inflammation of membrane lining of abdominal well of intestines

Monitor for complications

Creates widespread inflammation of mainly the rectum and rectosigmoid colon but can extend to the entire colon when the disease is extensive - all layers of bowel Etiology: unknown; but some genetic components, immunologic, and environmental factors likely contribute to disease

Ulcerative colitis

In addition to the report of diarrhea, what other clinical manifestation might the client report? A. Poor skin turgor B. Confusion C. Increased weight D. Clay colored stool

Answer: A Dehydration - lot of stool so at risk for dehydration; look at skin turgor and other s/s of dehydration 10-20 stools

What clinical manifestations of ulcerative colitis make Molly at higher risk for decreased oxygenation and fatigue? A. Bloody stools B. Fever C. Electrolyte abnormalities D. Elevated inflammatory markers

Answer: A Decreased Hgb so higher risk for decreased in oxygenation and when anemic would be tired

10-20 liquid/loose, bloody stools per day - decreased Hgb Stool may contain mucus Tenesmus (an unpleasant and urgent sensation to defecate) Lower abdominal colicky pain relieved with defecation Malaise Anorexia Anemia Dehydration - poor skin turgor Fatigue with anemia - decreased Hgb Fever Weight loss - due to stools Anemia Increased WBC Elevated C-reactive protein and ESR - indicate inflammation Decreased electrolytes - given number stools

Molly does not have any other GI symptoms at this time. What are some other symptoms she might experience? - Clinical manifestations:

Molly is scheduled for a flexible sigmoidoscopy and barium enema. How should the nurse explain the flexible sigmoidoscopy? A. X-ray is used to visualize the large intestine after barium is instilled B. Visual exam using a fiberoptic scope of the upper GI tract C. Visual exam using a fiberoptic scope of the rectum and sigmoid colon D. A digital rectal exam after an enema

Answer: C

Clear liquids typically the day before and sometime NPO the day of the procedure One to two enemas the day of the procedure Does not require total bowel cleanse as required for a colonoscopy

What type of prep is required for a sigmoidoscopy?

Increase fluids to facilitate the excretion of the barium from the colon - get barium out of colon: PO/IV

What post op procedure instructions should the nurse include post barium enema?

Which clinical manifestation would be concerning to the nurse following the flexible sigmoidoscopy? A. Temperature B. Rigid abdomen C. Decreased urine output D. Inelastic skin turgor

Answer: B

Bowel perforation and possible peritonitis

What complication does this assess for?

Abdominal guarding with pain, boardlike abdomen when palpating, strong pain; feel very hard

What are other signs and symptoms?

Decrease inflammation

Prednisone:

Decrease inflammation

Sulfasalazine:

Suppress immune system so does not overreact

Azathioprine:

Immunomoduators are given to suppress the immune system Glucocorticoids are used during exacerbation to decrease inflammation Aminosalicylates are used to decrease inflammation Antidiarrheals are given cautiously - lot stools but not want increased pressure on large intestine and enlarge colon

Drug therapy: - Ulcerative colitis: treatment:

NPO TPN - nutrition through central line; depending on how long be NPO Avoid caffeine, alcohol, raw vegetables, high fiber foods (decrease peristalsis), lactose containing foods

Nutrition therapy: - Ulcerative colitis: treatment:

Can reduce intestinal activity, provide comfort, and promote healing

Restrict activity - Ulcerative colitis: treatment:

Hbg and Hct Electrolyte values VS

Monitor for GI bleeding - Ulcerative colitis: treatment:

Removal of colon if other meds or other treatment not effective

Surgery may be required if medical therapies alone are not effective - Ulcerative colitis: treatment:

Begins in rectum and proceeds toward the cecum

Location - Ulcerative colitis

Unknown

Etiology - Ulcerative colitis

15-25 and 55-65

Age of incident - Ulcerative colitis

10-20 liquid, bloody

stools per day - Ulcerative colitis

Hemorrhage Nutritional deficiencies - all bowel movement

Complications - Ulcerative colitis

Infrequent

Need for surgery - Ulcerative colitis

Most often in terminal ileumm can also involve colon with patchy involvement throughout all layers of bowel - lots surgeries to help; patchy areas; skipped lesions

Location - Crohn’s disease

Unknown

Etiology - Crohn’s disease

15-40

Age of incident - Crohn’s disease

5-6 soft, loose nonbloody

stools per day - Crohn’s disease

Fistualas (common) Malabsorption and nutritional deficiencies - all bowel movement Obstructions due to inflammation and scarring

Complicatins - Crohn’s disease

Frequent

Need for surgery - Crohn’s disease

Chronic inflammatory disease of the small intestine (most often), the colon, or both Presents as inflammation that causes a thickened bowel wall Etiology: unknown, but may include genetic, immune, and environmental factors Clinical Manifestations: Lab findings: Diagnostic testing: Treatment

Crohn’s disease

Noted by “skip” lesions Involves all the layers of the intestinal wall

Presents as inflammation that causes a thickened bowel wall - Crohn’s disease

5-6 soft, loose stools per day, non-bloody Abdominal pain Low-grade fever Weight loss

Clinical Manifestations: - Crohn’s disease

Anemia Decreased folic acid and Vitamin B12 Decreased albumin levels Elevated C-reactive protein and ESR - indicates inflammation

Lab findings: - Crohn’s disease

X-ray: shows narrowing, ulcerations and strictures Magnetic resonance enterography (MRE): determine bowel activity/motility Abdominal ultrasound Abdominal computerized tomography Colonoscopy GI bleeding scan

Diagnostic testing: - Crohn’s disease

Immunomodulators are given to suppress the immune system Glucocorticoids are used during exacerbation to decrease inflammation Aminosalicylates are used to decrease inflammation Antidiarrheals are given cautiously - not want enlarge colon

Treatment - Drug therapy: - Crohn’s disease

NPO TPN Nutritional supplements

Nutrition therapy - Drug therapy: - Crohn’s disease

Treatment includes nutrition and electrolyte therapy, skin care, and prevention of infection - skin involved get wound or skin therapy involved

Fistulas (abnormal tracts between two or more body areas) are common - Drug therapy: - Crohn’s disease

Might be needed: Not as successful because inflammation occurs along all areas/layers of the bowel involved so might need multiple/frequent surgeries

Surgery may be needed - Drug therapy: - Crohn’s disease

A client is admitted to the hospital with left lower quadrant pain, an elevated temperature. What problem might the nurse expect based on these clinical manifestations? A. Gastroenteritis B. Diverticulitis C. Ulcerative Colitis D. Crohn’s Disease

Answer: B

Abdominal pain (LLQ) Temperature > 101 F - elevated temp Lower GI bleeding Nausea

Clinical manifestations of diverticulitis:

An abdominal computerized tomography (CT) is performed to confirm diagnosis of diverticulitis. A complete blood count is also completed. What results does the nurse anticipate? A. Elevated hemoglobin B. Decreased platelet count C. Elevated white blood cell count D. Decreased bilirubin

Answer: C

Gastroenteritis is an inflammation of the mucous membranes of the stomach and intestinal tract usually secondary to a virus or bacteria - ate something bad or stomach virus Diverticulitis is an inflammation of diverticuli (outpouching of the intestinal wall) in the intestines

The client tells the nurse that they just think they ate “something bad”. How best does the nurse explain the difference between gastroenteritis and diverticulitis?

nausea/vomiting; diarrhea; abdominal cramping; can lead to dehydration - n/v/d

Clinical manifestations: - Gastroenteritis

Oral rehydration or IV fluids - can be treated as outpt but if dehydration bad need IVF Monitor VS, I/O, weight VS decreased because of diarrhea Monitor electrolytes Drugs that suppress intestinal motility (antidiarrheals) are usually not administered - ammodium carefully given Antibiotics to treat bacterial gastroenteritis and anti-infective Prevent transmission to others

Management: - Gastroenteritis

Potassium may be needed for patients with excessive diarrhea

Monitor electrolytes

These drugs can prevent the infecting organisms from being eliminated from the body

Drugs that suppress intestinal motility (antidiarrheals) are usually not administered - ammodium carefully given

Hand hygiene Sanitize environmental items Proper food preparation

Prevent transmission to others

Hypotension and tachycardia - VS Decrease in H&H

GI bleeding - What complications would nurse be alert for when caring for a client with diverticulitis?

Severe abdominal pain and guarding Rigid board like abdomen Rebound tenderness - pain when lets go

Rupture of diverticuli and peritonitis - comp want to look out for: symp: - What complications would nurse be alert for when caring for a client with diverticulitis?

IV fluids Drug therapy: Assess fluid and electrolyte imbalance - check labs Avoid increasing intra abdominal pressure Diet modification NGT Surgery

What should be included in the management of care for a client diagnosed with diverticulitis?

Antimicrobial Mild analgesic for pain or opioid analgesic - depending on how bad pain Avoid laxatives or enemas as they increase intestinal motility

Drug therapy:

NPO, clear liquids, or low fiber diet - decrease peristalsis Fiber containing diet is gradually introduced when inflammation has resolved and bowel function returns to normal

Diet modification

If N/V or abdominal distention is severe

NGT

Indicated if peritonitis, bowel obstruction or pelvic abscess is present - emergency Colon resection, with or without colostomy

Surgery

Gastrointestinal Case Studies Flashcards

(80 cards)