week 11: lower gi

Question 1

Etiology and Pathophysiology of Acute Abdominal Pain (Cont.)

Answer 1

if any of the complications continue, the person can going to septic shock or hypovolemic shock

Question 2

Acute Abdominal Pain

Can be from many causes

Answer 2

Common ones include appendicitis, blunt trauma, cholecystitis, Crohn’s disease, Divierticulitis, gastritis, GI malignancy etc (see your textbook for a list)

Question 3

Acute Abdominal Pain

Primary symptom is pain

Answer 3

May also include abdo tenderness, N, V, diarrhea, constipation, flatulence, fatigue, fever, abdo distension

Question 4

Diagnosis

Acute Abdominal Pain

Answer 4

1.--Complete history and physical:
VS, watch for hypovolemia; ? Fever; inspect for distension/masses/rash etc
PQRSTU
Bowel sounds
Diarrhea? N & V – noting characteristics of stool/vomitus
--Physical – rectal, pelvic exam
3.CBC, Urinalysis
4.Abdo U/S
5.Pregnancy test (BHcG)

Question 5

Managing Acute Abdo

Answer 5

-Stabilize the patients condition
(Manage pain, N & V)

-Identify and treat cause
(Aim for appropriate nutrition
No complications)

• Keep NPO, start IV
• Surgery may or may not be needed
• Surgery may also be done to ‘explore’ to determine diagnosis

Question 6

Nursing diagnosis

Answer 6

Acute pain

Imbalanced nutrition (less)

Anxiety

Altered fluid and electrolytes

Question 7

nursing role

Answer 7

Consent, education for pre/post op
OR forms
NPO

Pre op care–Ensure pre op bloodwork done (CBC, type and screen, and clotting studies)
Foley, pre op antibiotic
Insert NG tube
Manage pain

Question 8

Post op care

Answer 8

-Depends on type of surgery
-Open (long incision):
Longer LOS
Increased incidence of GI motility alterations
Increased risk of complications

Laparoscopic (several tiny incisions)

Assess bowel sounds – passing gas, burping
Stomach motility – returns 24 – 48 hours
Small intestine returns 12 – 24 hours
Large intestine up to 3 to 5 days

NG tube – usually to low suction, patency

Consider what the anticipated drainage will be
Upper – dark brown/red changing to yellow/brown
If bright red or dark red continues notify MD

Observe for return of peristalsis – usually can DC NG

May receive TPN, IV fluids
Drains
N & V – antiemetics as required
Management of pain
Mobilization
DB & C
Incision care, splinting incision
Abdo distension and gas pains common

Question 9

Irritable Bowel Syndrome (IBS)

Answer 9

Chronic disorder (NOT a psychological disorder)

Functional, intermittent and recurrent abdominal pain associated with altered bowel function (diarrhea, constipation, or both)

Affects up to 20% of Canadians

Question 10

IBS

Symptoms

Answer 10

Abdominal bloating, excessive gas, urge to defecate, urgency, feeling of incomplete evacuation

Question 11

IBS

CAUSES

Answer 11

Possible neurological hypersensitivity of GI tract
Physical, emotional stress
Dietary issues
Antibiotics
Infections
Chronic alcohol intake
Changes in peristalsis
Intestinal irritation

Question 12

IBS

ASSESSMENT

Answer 12

Detailed history and physical required
Resembles many other disorders

ROME III Criteria:

1. Abdo discomfort or pain for at least 3 months, with onset at least 6 months prior
2. WITH at least 2 of the following:
   - Relieved with defecation
   - Onset associated with change in stool frequency
   - Onset associated with change in stool appearance

Question 13

IBS

Health Teaching

Answer 13

High fibre diet +/- Metamucil
Eliminate gas producing foods
Lactose free products
Tegaserod – med that assists movement of stool through colon

Stress reducing measures
Antidepressants
Acupuncture

Question 14

Appendicitis

Answer 14

Inflammation of appendix; occlusion by accumulated feces

Question 15

S&S

Appendicitis

Answer 15

Periumbilical pain, with anorexia, N, V; persistent pain moving to RLQ (McBurneys point)

Question 16

Diagnosis

Appendicitis

Answer 16

Hx and physical,
Abdo palpation
CBC
Urinalysis

Question 17

Appendicitis

TX

Answer 17

NPO to ensure that the stomach is empty in the event that surgery is needed

Sx –
if ruptured and peritonitis, then antibiotics prior

Local application of heat is not advised because it may cause the appendix to rupture

Question 18

Gastroenteritis

Answer 18

Inflammation of mucosa of stomach

Question 19

S/S

Gastroenteritis

Answer 19

N, V, diarrhea, cramping, distension; +/- fever, elevated WBC, blood/mucus stool

Question 20

DX

Gastroenteritis

Answer 20

Hx and Physical

Question 21

TX

Gastroenteritis

Answer 21

IV if dehydrated
Usually self limiting
I and O***
NPO until no vomiting
Consider isolating pt
Rest

WATCH FOR DEHYDRATION

Question 22

Peritonitis

Answer 22

Can be an emergency!

Usually very ill

Watch for sepsis

Inflammation of peritoneum; usually rupture of organ or trauma

Can lead to hypovolemic shock, septicemia, abscess, organ failure

Question 23

S/S

Peritonitis

Answer 23

Abdo pain; tenderness over affected area; Rebound tenderness,muscle rigidity, spasm; +/- fever, elevated P, BP, N, V

Question 24

DX

Peritonitis

Answer 24

CBC
Peritoneal aspiration (determine what the fluid is)
Abdo Xray

Question 25

TX | Peritonitis

Answer 25

``` NPO Antibiotics Pain management IV fluids I & O NG Knees flexed for comfort ```

Question 26

Nursing Management: Diverticulitis

Answer 26

Uncomplicated disease is treated with a high-fibre diet and bulk laxatives, such as psyllium hydrophilic mucilloid (Metamucil) In acute diverticulitis, the goal of treatment is to allow the colon to rest and the inflammation to subside. 1. Keep patient NPO status with IV fluids for hydration. 2. Observe patient for signs of possible peritonitis. 3. Administer broad-spectrum antibiotic therapy. 4. Monitor temperature and WBC count.

Question 27

Ulcerative Colitis

Answer 27

Inflammatory bowel disease (IBD) Autoimmune disease Idiopathic inflammation and ulcerations Damage caused by overactive, inappropriate and sustained inflammatory response Teenage years, young adult; or 50’s – 70’s Varied clinical manifestations and unpredictable remissions

Question 28

Colitis

Answer 28

Acute, or chronic, flare ups Bloody diarrhea and abdominal pain - Mild case – 1 or 2 semi formed bloody stools/day - Moderate case – 4 -5 stools/day; increased bleeding, systemic symptoms (fever, malaise, wt loss) - Severe case – bloody diarrhea up to 20/per day, with systemic symptoms and significant weight loss

Question 29

COLITIS Can lead to

Answer 29

Perforation, hemorrhage, megacolon Increased risk of colon cancer Non colon symptoms – anemia, joint pain

Question 30

Diagnostics | COLITIS

Answer 30

CBC, lytes *Colonoscopy Stool cultures Multiple abscesses develop in the intestinal glands Abscesses break through into the submucosa, leaving ulcerations

Question 31

COLITIS CARE

Answer 31

``` Rest the bowel Control inflammation Mange fluids, nutrition Manage stress Symptomatic relief Education ```

Question 32

COLITIS Pharmacology

Answer 32

Sulphasalazine (5-ASA) – acute dosing and maintenance dosing 5-ASA enemas during acute phase Corticosteroids

Question 33

COLITIS SX

Answer 33

For severe cases, removing large portions of colon, rectum and anus Colostomy High percentage go into remission

Question 34

COLITIS Health Teaching

Answer 34

Recognizing dietary influences on disease Supporting pyschologically Compliance with pharmacological treatment

Question 35

If severe case | OF COLITIS...

Answer 35

TPN, accurate I & O, stool charting; pre/post surgery care Teaching care of ostomy Perianal care as required if frequent stooling

Question 36

Crohn’s

Answer 36

Inflammatory, chronic, affecting any part of the GI tract (most often terminal ileum and colon) Usually 15 – 30 year olds Inflammation occurs through all layers of bowel wall ‘skip’ lesions – areas of normal bowel with intermittent areas of lesions

Question 37

CROHNS CAN LEAD TO

Answer 37

Strictures, thickening of bowel wall Abscesses, fistulas connecting with other organs Peritonitis, perforation

Question 38

CROHNS S/S

Answer 38

partially dependent on area of bowel affected Non specific c/o diarrhea, fatigue, abdo pain, weight loss, fever KEY – diarrhea (usually not bloody) and abdo pain Can also cause malabsorption; may involve non GI symptoms (similar to UC)

Question 39

CROHNS Diagnostics

Answer 39

CBC, lytes Barium studies, endoscopy (capsule), sigmoidoscopy Stool cultures and for occult blood

Question 40

CROHNS TX

Answer 40

``` Rest the bowel Control inflammation Mange fluids, nutrition Manage stress Symptomatic relief Education ```

Question 41

Pharmacology | CROHNS

Answer 41

``` Sulphasalazine (5-ASA) – for large intestine invovlement Antibacterial/antimicrobials Corticosteroids Antidiarrheals Immunosuppresants Hematinics, vitamins ```

Question 42

CROHNS SX

Answer 42

For severe cases, although it will recur Often due to complications Most with crohn’s will have a surgery at some point

Question 43

CROHNS Health Teaching

Answer 43

* Diet – low residue, roughage and fat; high calories and protein; elemental diets – absorbed in the proximal small bowel * Support psychologically * Compliance with pharmacological treatment * Reduce stress * Rest * Perianal care • If severe case- TPN, accurate I & O, stool charting; pre/post surgery care

Question 44

Intestinal Obstruction

Answer 44

``` Small intestine or large intestine Potentially life threatening Monitor fluid and electrolytes Watch for perforation/peritonitis NG tube Prepare for surgery ```

Question 45

Intestinal Obstruction ASSESSMENT

Answer 45

Detailed hx and physical ``` PQRSTU Tenderness, rigidity Vomiting – characteristics Bowels – passing gas? Stool? Auscultate, inspect ```

Question 46

U. COLITIS ETIO AND PATHO

Answer 46

Ulcerations destroy the mucosal epithelium, causing bleeding and diarrhea Fluid and electrolyte losses Protein loss Pseudopolyps